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Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
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47
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Academy of Orthopaedic Physical erapy, APTA.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
The Shoulder:
https://t.me/med1917
Evidence-Informed Physical
Therapy Patient Management
Independent Study
Course 31.2.5
Amee L. Seitz, PT, PhD, DPT
Northwestern University
Chicago, IL
Heather Christain, PT, DPT, OCS, SCS
Rally Physical Therapy
Highland Park, IL
Northwestern University
Chicago, IL
Adam Lutz, PT, DPT, PhD
ATI Physical Therapy &
South Carolina SmartState Center for
Effectiveness Research in Orthopaedics
Greenville, SC
Ellen Shanley, PT, PhD, OCS
ATI Physical Therapy &
South Carolina SmartState Center for
Effectiveness Research in Orthopaedics
Greenville, SC
The Shoulder:
https://t.me/med1917
Evidence-Informed Physical
Therapy Patient Management
Guy G. Simoneau, PT, PhD, FAPTA—Editor
Dhinu Jayaseelan, PT, DPT, OCS, FAAOMPT—Associate Editor
Cover Illustration by Joseph Kinstler
Dear Colleagues,
I am pleased to welcome you to e Shoulder: Evidence-Informed Physical erapy Patient Management monograph written by Amee L. Seitz, PT,
PhD, DPT, Heather Christain, PT, DPT, OCS, SCS, Adam Lutz, PT, DPT, PhD, and Ellen Shanley, PT, PhD, OCS. is work is part of the Academy
of Orthopaedic Physical erapy Independent Study Course series 31.2, Current Concepts of Orthopaedic Physical erapy, 5th Edition.
Amee L. Seitz is an Associate Professor and Musculoskeletal Team Leader in the Department of Physical erapy and Human Movement Science, Feinberg School of Medicine, at Northwestern University in Chicago, IL. Dr. Seitz has a Bachelor degree in Physical erapy from Ohio University, an Advanced Masters degree in Orthopaedic Physical erapy and transitional DPT from the MGH IHP, and a PhD in Rehabilitation Science from Virginia
Commonwealth University. She has been an ABPTS board-certified Orthopaedic Clinical Specialist for the last 20 years. She is a contributing author of
the APTA Clinical Practice Guidelines for Adhesive Capsulitis and contributor on the writing panel of the American Academy of Orthopaedic Surgeon’s
Clinical Practice Guidelines for Rotator Cuff Injuries. She is Past-President of the American Society of Shoulder & Elbow erapists (ASSET). She
mentors PhD students, residents, and fellows. Her research focus seeks to elucidate neuromuscular and biomechanical mechanisms of upper extremity
musculoskeletal disorders to improve patient outcomes. She has published peer-reviewed manuscripts and presented nationally and internationally on
musculoskeletal shoulder injury, mechanisms, and evidence-based rehabilitation. Dr. Seitz has been awarded the ASSET Founders award and the James
A. Gould Excellence in Teaching Orthopaedic award.
Heather Christain is an ABPTS board-certified clinical specialist in both sports and orthopaedics and works as an outpatient physical therapist at Rally
Physical erapy in Highland Park, IL. She attended the University of Iowa where she completed a Bachelor of Science in Engineering and her DPT.
She is an associated faculty and contract educator for the DPT Program at Northwestern University in the Musculoskeletal Course Series. She has served
as residency faculty for the shoulder didactic component in the Sports and Orthopaedic Residency Programs at the University of Pittsburgh Medical
Center Centers for Rehab Services in Pittsburgh, Pennsylvania.
considerations and co-authored a previous monograph by the Academy on the Post-operative Management for Orthopaedic Surgeries on the Shoulder.
Adam Lutz earned his Bachelor of Science degree in Kinesiology at Louisiana State University. He then attended University of North Florida where he
completed his DPT. He subsequently completed his PhD in Rehabilitation Sciences with a focus on Health Services Research at the University of South
Carolina. He currently serves as Director of Market Research & Development at ATI Physical erapy where he teaches in the Orthopedic & Sports
Residencies. He is also Research Associate with the South Carolina SmartState Center for Effectiveness Research in Orthopaedics (CEROrtho) and an
Adjunct Faculty with the University of South Carolina’s Physical erapy Program. Adam has helped guide ATI’s national outcome strategy including
risk-adjustment of the most commonly used patient reported outcomes and published in peer-reviewed journals, and routinely presented in national
conferences.
Ellen Shanley is a clinical research scientist for ATI and serves as the Director of Athletic Injury Research, Prevention, and Education for the South
Carolina Center for Effectiveness Research in Orthopedics. She also serves as faculty at the University of South Carolina in the School of Public Health,
Clemson University School of Bioengineering, and Rocky Mountain University of Health Professions PhD program. She functions as Senior Faculty in
an APTA credentialed sports residency and is a co-founder of the APTA credentialed upper extremity fellowship for ATI and the Kansas City Royals.
She has previously and continues to mentor residents, fellows, and PhD students. Dr. Shanley has served as the Education Chair and Past President for
the American Shoulder and Elbow Surgeons and ASSET. She has been awarded the APTA’s excellence in research award and ASSET’s Founders Award.
Dr. Shanley is an associate editor for the Journal of Shoulder and Elbow Surgery. She has published and/or presented regionally, nationally, and internationally on identification and modification of risk factors, rehabilitation, and returning youth through professional athletes to play.
In this monograph, the authors provide a contemporary perspective of assessment and treatment of the most common shoulder conditions. Concepts
of screening (red and yellow flags), determining the underlying pain mechanism, and clinical-reasoning combining pathoanatomy, diagnostic “labels,”
and impairments are thoroughly discussed in an integrative manner. is monograph provides a great update on current practice for both non-operative
and post-operative management of shoulder conditions.
My sincere thanks to the authors for their contribution to the Current Concepts series.
Sincerely,
She has published peer-reviewed manuscripts on post-operative shoulder return to play
Guy Simoneau, PT, PhD, FAPTA
Editor
2920 East Avenue South, Suite 200 | La Crosse, WI 54601 | Office 608-788-3982 | Toll Free 800-444-3982 | Fax 608-788-3965
TABLE OF CONTENTS
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ACRONYM LIST ................................................................................................................................................................................................................5
ABSTRACT
LEARNING OBJECTIVES
CLINICAL ANATOMY, KINESIOLOGY, AND BIOMECHANICS
..........................................................................................................................................................................................................................7
.............................................................................................................................................................................................7
...................................................................................................................7
Passive Structures and Constraints to Anterior – Posterior Movement .......................................................................................... 7
Glenohumeral anatomy ......................................................................................................................................................... 7
Glenohumeral pathoanatomy.................................................................................................................................................8
Acromioclavicular and sternoclavicular anatomy .................................................................................................................... 9
Acromioclavicular and sternoclavicular pathoanatomy ......................................................................................................... 10
Glenohumeral ligaments ...................................................................................................................................................... 10
Glenohumeral ligamentous pathoanatomy ........................................................................................................................... 11
Labrum ................................................................................................................................................................................ 11
Labral pathoanatomy ........................................................................................................................................................... 12
Active Structures and Constraints to Movement ..........................................................................................................................12
Rotator cuff anatomy ........................................................................................................................................................... 12
Force couples ....................................................................................................................................................................... 13
Rotator cuff pathoanatomy .................................................................................................................................................. 13
Rotator cuff tears ................................................................................................................................................................. 14
Scapulothoracic anatomy ..................................................................................................................................................... 15
Biomechanics of the scapula ................................................................................................................................................. 15
Scapular dyskinesis ............................................................................................................................................................... 16
Summary and Implications for Practice ....................................................................................................................................... 17
CLINICAL EXAMINATION AND DECISION-MAKING PROCEDURES ................................................................................................. 17
Patient History and Interview ..................................................................................................................................................... 17
Clinical Reasoning to Classify Shoulder Pain: STAR Shoulder .................................................................................................... 19
Level One: Screening .................................................................................................................................................................. 20
Red flags .............................................................................................................................................................................. 20
Role of imaging ................................................................................................................................................................... 21
Yellow flags .......................................................................................................................................................................... 23
Level Two: Specific Examination and Classification .....................................................................................................................24
Tests and measures ............................................................................................................................................................... 24
Concordant sign ................................................................................................................................................................. 24
Observation and inspection ................................................................................................................................................. 24
Scapular position ................................................................................................................................................................ 25
Cervical and neurological screen ......................................................................................................................................... 25
Active range of motion ......................................................................................................................................................... 26
Palpation ..............................................................................................................................................................................27
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
3
Passive joint mobility .......................................................................................................................................................... 27
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Muscle performance ............................................................................................................................................................. 28
Special tests .......................................................................................................................................................................... 29
CONDITIONS-SPECIFIC EVIDENCE-BASED REHABILITATION CONCEPTS FOR NOCICEPTIVE PAIN
........................... 35
Nociceptive, Nociplastic, and Neuropathic Pain Mechanisms Considerations ............................................................................. 35
Level ree: Rehabilitation Classification and Matched Interventions ........................................................................................ 35
Patient education ................................................................................................................................................................. 35
Adhesive capsulitis: mobility deficit ...................................................................................................................................... 37
Subacromial pain syndrome: muscle performance deficit ..................................................................................................... 38
Full-thickness rotator cuff tear ............................................................................................................................................. 39
Instability: motor coordination deficits ................................................................................................................................ 40
Superior labrum, anterior to posterior injuries ..................................................................................................................... 43
Other Diagnoses ........................................................................................................................................................................ 43
Proximal humeral fracture ....................................................................................................................................................43
Acromioclavicular joint injury ............................................................................................................................................. 43
Glenohumeral joint osteoarthritis ........................................................................................................................................ 44
Post-operative Rehabilitation Principles ......................................................................................................................................45
Rotator cuff repair post-operative rehabilitation ................................................................................................................... 45
SLAP, capsulolabral, and Bankart repair post-operative rehabilitation...................................................................................46
Latarjet post-operative rehabilitation ................................................................................................................................... 47
Total shoulder arthroplasty (anatomical and reverse) post-operative rehabilitation .............................................................. 47
PATIENT TREATMENT OUTCOMES .................................................................................................................................................................... 48
Patient-Reported Outcome Measures ......................................................................................................................................... 48
Regional Specific Outcome Tools ............................................................................................................................................... 48
Condition-Specific Outcome Tools ............................................................................................................................................. 50
Other Patient-Reported Outcome Measures ................................................................................................................................50
Measurement Properties .............................................................................................................................................................. 50
Functional Testing and Return to Participation ........................................................................................................................... 51
Risk-Adjustment Using Patient-Reported Outcome Measures ..................................................................................................... 51
Summary and Implications for Practice ....................................................................................................................................... 51
CONCLUSION ................................................................................................................................................................................................................ 51
CASE SCENARIOS ........................................................................................................................................................................................................ 52
Case Scenario 1 .......................................................................................................................................................................... 52
Case Scenario 2 .......................................................................................................................................................................... 53
Case Scenario 3 .......................................................................................................................................................................... 56
Case Scenario 4 .......................................................................................................................................................................... 58
APPENDIX .......................................................................................................................................................................................................................61
REFERENCES..................................................................................................................................................................................................................65
Academy of Orthopaedic Physical erapy, APTA.
4
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
ACRONYM LIST
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AC: acromioclavicular
ADL: activity of daily living
AMBRI: Atraumatic, Multidirectional, Bilateral,
Rehabilitation, Inferior capsular shift
ASES: Association of Shoulder and Elbow
Surgeons
CC: coracoclavicular
CKCUEST: Closed Kinetic Chain Upper Extremity
Stability Test
CT: computed tomography
DASH: Disabilities of the Arm, Shoulder, and Hand
EMG: electromyography
ER: external rotation
GH: glenohumeral
GIRD: glenohumeral internal rotation deficit
HAGL: humeral avulsion of the inferior
glenohumeral ligament
HHD: hand-held dynamometer
HRQoL: health-related quality of life
ICC: intraclass correlation coefficient
ICF: International Classification of Functioning,
Disability and Health
IR: internal rotation
-LR: negative likelihood ratio
+LR: positive likelihood ratio
MCID: minimal clinically important difference
MDC: minimal detectable change
MDI: multidirectional instability
MRA: magnetic resonance arthrogram
MRI: magnetic resonance imaging
MVC: maximum voluntary contraction
OA: osteoarthritis
OR: odds ratio
PROM: patient-reported outcome measure
PSET: Posterior Shoulder Endurance Test
PSFS: Patient Specific Functional Scale
PSS: Penn Shoulder Score
qDASH: Quick Disabilities of the Arm, Shoulder,
and Hand
ROM: range of motion
SANE: Single Assessment Numeric Evaluation
SARTS: Shoulder Arm Return-to-Sports
SC: sternoclavicular
SCB: substantial clinical benefit
SEM: standard error of the measure
SF-36: Short-Form 36-Item Health Survey
SLAP: superior labrum, anterior to posterior
SMBT: Seated Medicine Ball row
SPADI: Shoulder Pain and Disability Index
SRM: standardized response mean
STAR-Shoulder: Stage Approach for Rehabilitation
Classification for the Shoulder
TFAST: Timed Functional Arm and Shoulder Test
TSA: total shoulder arthroplasty
TUBS: Traumatic, Unilateral, Bankart lesion,
Surgery
VAS: visual analog scale
VR-12: Veteran’s RAND 12-Item General Health
Survey
WOOS: Western Ontario Osteoarthritis
Index of the Shoulder
WORC: Western Ontario Rotator Cuff Index
WOSI: Western Ontario Shoulder Instability Index
YBT-UQ: Y-Balance Test – Upper Quarter
Academy of Orthopaedic Physical erapy, APTA.
For personal use only. No other uses without permission.
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
Opinions expressed by the authors are their own and do not necessarily reflect the view of the
Academy of Orthopaedic Physical erapy. e authors declare no conflict of interest.
e publishers have made every effort to trace the copyright holders for borrowed material.
If we have inadvertently overlooked any, we would be willing to correct the situation at the first opportunity.
© 2021, Academy of Orthopaedic Physical erapy. For personal use only. No other uses without permission.
Course content is not intended for use by participants outside the scope of their license or regulations.
5
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6
The Shoulder:
https://t.me/med1917
Evidence-Informed Physical
Therapy Patient Management
Amee L. Seitz, PT, PhD, DPT
Northwestern University
Chicago, IL
Heather Christain, PT, DPT, OCS, SCS
Rally Physical erapy
Highland Park, IL
Northwestern University
Chicago, IL
Adam Lutz, PT, DPT, PhD
ATI Physical erapy &
South Carolina SmartState Center for Effectiveness Research
in Orthopaedics
Greenville, SC
Ellen Shanley, PT, PhD, OCS
ATI Physical erapy &
South Carolina SmartState Center for Effectiveness Research
in Orthopaedics
Greenville, SC
ABSTRACT
is monograph begins with a review of anatomy and
biomechanics of the shoulder that is clinically relevant to the
evaluation and treatment of non-operative and post-operative
shoulder conditions. Signs and symptoms for the differential
diagnosis of common conditions and underlying pain
mechanisms affecting the shoulder are presented. Evaluation
using evidence-based tests and measures is reviewed to guide
classifying patients within a diagnosis and rehabilitation
classification associated with the movement problem. e
authors summarize evidence-based treatment interventions
based on tissue irritability stage to best prioritize and resolve
impairments of movement problems across the continuum
of care. An emphasis is placed on best-available evidence and
Clinical Practice Guidelines recommendations. Several nonoperative and post-operative rehabilitation guidelines are
discussed to facilitate evidence-based treatment progression.
Outcome tools for a variety of shoulder and regional disorders,
as well as performance-based measures with psychometric
properties relevant to evaluate patient progress are also included.
e monograph concludes with 4 patient case scenarios to
allow readers an opportunity to apply clinical reasoning skills
integrating the concepts for examination and management of
patients with shoulder pain presented within the monograph.
Key Words: adhesive capsulitis, clinical practice guidelines,
instability, rotator cuff
LEARNING OBJECTIVES
Upon completion of this monograph, the course participant
will be able to:
1.
Identify and discuss anatomical and biomechanical factors to
integrate into the examination, evaluation, and intervention
of non-operative and post-operative shoulder dysfunction.
Use common evidence-based history and examination
2.
findings to rule in and out various shoulder pathoanatomic
diagnoses.
4.
Critique the use of pathoanatomic shoulder diagnoses for
patients seen in physical therapy practice.
Recognize characteristics for suspected red flags in patients
5.
with shoulder symptoms that necessitate referral and/or
need for imaging.
6.
Apply evidence on rehabilitation compared to surgical
intervention for a variety of shoulder pathologies into
patient education as part of an informed decision-making
process for management.
Select appropriate interventions based on pain severity,
7.
irritability, and contributing impairments to the movement
problems associated with various shoulder conditions.
8.
Define the various restrictions for a variety of post-operative
shoulder procedures based on tissue healing and timelines
for immobilization, range of motion, strength, and return to
function phases of rehabilitation.
Identify the available patient-reported outcome tools that
9.
may be best to determine the patient’s health-related quality
of life and regional- or disease-specific pain and disability
level.
CLINICAL ANATOMY, KINESIOLOGY,
AND BIOMECHANICS
Passive Structures and Constraints
to Anterior – Posterior Movement
e shoulder (glenohumeral [GH] joint) is inherently
the most mobile joint in the body; which necessitates a
combination of passive and active structures to provide stability.
Passive structures that contribute to shoulder stability include
the bony surfaces of the humeral head and glenoid and the
anterior and posterior capsulolabral ligamentous structures,
otherwise known as the ligaments and the labrum. e
anterior capsulolabral ligamentous complex consists of the
anterior GH ligaments along with anterior labrum, glenoid
fossa, periosteum, and subscapularis musculotendinous unit.
e posterior capsulolabral ligamentous complex consists of
the posterior labrum, glenoid fossa, periosteum, and posterior
1
capsule.
Glenohumeral anatomy
e GH joint is a synovial joint between the head of the
humerus and the shallow glenoid of the scapula. e glenoid
is conventionally considered to be pear-shaped, although there
Academy of Orthopaedic Physical erapy, APTA.
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7
is some variability. e glenoid is the most lateral aspect of the
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scapula, which itself is anteverted 30° in reference to the coronal
2
e glenoid is tipped superiorly, or inclined, in relation
plane.
to the scapula. e orientation of the articular surface of the
glenoid is posterior (termed retroverted) in reference to the
transverse plane of the scapular axis. e degree of retroversion
varies, but on average is less than 7°.
3
e humeral head is oriented medially, superiorly, and
slightly posteriorly to align with a laterally oriented glenoid. e
humerus also demonstrates a varying degree of retroversion.
3
e amount of retroversion is dependent on sex, history
(type) of sporting activities, and the methodology used for
2
measurements.
ere is also a significant difference between
dominant and non-dominant shoulders, with dominant
shoulders demonstrating increased retroversion. Although
there is a strong association between the amount of humeral
retroversion and an increase in external rotation (ER) range of
motion (ROM) combined with a decrease in internal rotation
(IR) ROM, total rotation ROM of the GH joint is not affected
by the amount of humeral retroversion.
4
At any given time, only one third of the humeral head is
in contact with the glenoid fossa. is allows for multiaxial
movement, but with high demand for muscular control.
3,5
e effective glenoid arc is defined as the area of the glenoid’s
articular surface available for humeral head compression/
6
contact.
e angle between the glenoid arc and the center of
the glenoid is called the balance stability angle. It measures the
contact area of the glenoid and humeral head. If the resultant
forces from surrounding musculature are directed outside of the
balance stability angle, GH joint stability can be compromised.
Glenohumeral pathoanatomy
Glenoid abnormalities are present in a few shoulder
pathologies. Contrasting views exist regarding a potential
association between rotator cuff pathology and an increase in
glenoid inclination and or retroversion. It has been suggested
that superior inclination of the glenoid predisposes patients
7
to rotator cuff pathogenesis;
conversely, increasing superior
inclination has not been associated to superior humeral head
8
migration.
Shoulders may have greater than 7° of retroversion
of the glenoid due to a developmental abnormality, primary
osteoarthritis (OA), secondary post-traumatic arthritis, or
9
inflammatory conditions.
Wear patterns on the glenoid can
vary due to the etiology of the arthritic condition and are
considered either concentric or eccentric. Glenoid erosion can
be classified as either central or posterior with subgroups based
10
on the extent of wear and subluxation (Figure 1).
Concentric
wear is symmetrical or even along the surface of the glenoid,
but can vary in the extent of bony erosion (Type A). Concentric
wear demonstrates continued centration of the humeral head
10
on the glenoid.
Eccentric morphological changes demonstrate
uneven wear of the posterior glenoid, resulting in glenoid
retroversion and posterior humeral head subluxation, though
Figure 1.
Morphologic Types of the Glenoid in
Primary Osteoarthritis*
*Adapted from Walch et al.10 Illustration by Kinstler Design.
3
the extent of this can vary (Type B).
Type B morphological
changes range from posterior joint space narrowing to a
10
biconcave glenoid.
Type C glenoid morphology is defined by a
glenoid retroversion of more than 25° and is categorized as such
regardless of the erosion or respective location of the humeral
10
An IR contracture and posterior GH joint instability
head.
are common findings with advanced posterior glenoid erosion.
3
Morphologic changes as mentioned with primary OA can
3
either be the result or the cause.
Nonetheless, patients are 9
times more likely to have recurrent instability if the glenoid
retroversion angle is less than 6°.
3
With the advances in total joint restoration techniques, the
rate of total shoulder arthroplasty (TSA) surgery is increasing at a
much higher rate compared to that of hip and knee replacements.
Between 2011 and 2017, primary TSA procedures increased
by 103%, as compared to 17.8% for total knee arthroplasties
11
and 29.1% for total hip arthroplasties.
After the diagnosis,
frequently pre-operative computed tomography (CT) scans are
used to identify glenoid version to adequately plan for surgical
correction. For those undergoing TSA, eccentric deformities
have been shown to have a negative impact with a higher
12
failure rate compared to those with concentric deformities.
Clinicians may benefit from understanding the underlying OA
morphology type when designing the rehabilitation program
for patients following a TSA.
Glenoid version also plays a role in shoulder instability.
Glenoid anteversion predisposes the shoulder to anterior
13
instability.
Likewise, glenoid retroversion predisposes the
shoulder to posterior GH joint instability and posterior labral
13,14
tears.
A significantly decreased force is required for posterior
GH joint translation and dislocation in the presence of glenoid
13
retroversion.
In fact, it has been shown that a posterior soft
tissue shoulder stabilization surgery alone is not sufficient to
restore stability to the GH joint if the glenoid retroversion angle
13
is greater than 15°.
Glenoid osseus changes have been noted
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8
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