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accurate diagnostic hypotheses and may assist in selection of the
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110
initial interventions
to achieve improved patient treatment
outcomes.
Essential to the hypothesis generation is the patient’s report
of function, activity limitations, and participation restrictions.
e mechanism of injury can also help generate relevant
diagnostic hypotheses. If symptoms are related to overuse, then
tendinopathy or atraumatic instability may be suspected. In
contrast, a traumatic onset may be more indicative of a fracture,
rotator cuff tear, AC joint separation, or GH joint subluxation/
dislocation.
e clinician should gather information on the patient’s
own perspective of the problem and expectations for the
effectiveness of physical therapy management and outcome.
Patient expectations for recovery have been shown to be highly
114
predictive of treatment outcomes.
e clinician should also
use the history/interview to identify personal and environmental
factors that may impact both the patient’s risk for developing
specific hypothesized shoulder disorders and the prognosis for
recovery. Personal factors such as the patient’s age, physical
activity demands, relevant medical history such as diabetes or
smoking, and negative or positive psychosocial factors should
be assessed and interpreted within the context of the clinical
63,115
condition.
Environmental factors may include those related
to home, work, or community environment and social support
and can be used to inform the prognosis and intervention plan.
Clinical Reasoning to Classify Shoulder Pain:
STAR Shoulder
Physicians and other medical providers use pathoanatomicbased diagnostic labels for shoulder pain. Pathoanatomic
diagnoses are highly desired by patients and greater patient
116
satisfaction is found when imaging is used.
However, the
high-prevalence of asymptomatic pathoanatomical findings
117
on shoulder imaging,
suggest that shoulder pathoanatomy
may co-exists with pain from another anatomical source.
erefore, it could be misleading to directly assume that
shoulder pathoanatomy seen on imaging is the source of the
patient’s shoulder pain. ere is also uncertainty regarding
diagnostic physical exam criteria used for a variety of shoulder
pathologies and the underlying rationale for some of our
examination procedures and related clinical reasoning have
118-122
been challenged.
Lastly, the pathoanatomic diagnosis does
not always guide intervention choices in orthopaedic physical
123
therapy, as it does with surgical interventions.
For these
reasons, it has been proposed that physical therapists should not
solely rely on pathoanatomic diagnoses.
124
ere are, however, compelling reasons for physical
therapists to consider using hypothesized pathoanatomic
diagnoses. Contemporary literature used to inform the prognosis
of rehabilitation interventions for patients with musculoskeletal
shoulder disorders is largely based on pathoanatomic diagnostic
114,125-127
labels.
Using only terms physical therapists understand
to characterize the patient’s movement disorder limits the
credibility of physical therapists within an interdisciplinary
medical model system and our overall capability to be primary
point of entry as direct access providers. Using a medical model,
hypothesized pathoanatomic diagnoses that potentially require
128
a change in care pathway
and referral, can be efficiently
communicated with physicians and other health care providers
129
regarding the patient’s condition.
e Staged Approach for Rehabilitation Classification for
the Shoulder (STAR-Shoulder) overcomes these challenges
by integrating both pathoanatomic terms and rehabilitation
130
classification to guide clinical decision making.
e STARShoulder has 3 levels of classification (Figure 6). Level 1 is
the screening for red and yellow flags and is performed with
a history intake/interview and basic evaluation to determine if
the shoulder, cervical spine, or other somatic, visceral, vascular,
or systemic cause may account for the patient’s shoulder pain.
Level 2 is assigning a pathoanatomic diagnosis, which requires
a comprehensive examination of the patient to derive a primary
nociceptive shoulder classification category. e common
history and examination findings for each pathoanatomic
diagnostic category in the STAR-Shoulder are shown in Table
2. For those who do not meet the key findings of 1 of the 3
categories, the “other diagnoses” category applies, including
all post-operative conditions, fractures, and less frequently
encountered diagnoses such as AC joint conditions.
e third level, specific to rehabilitation classification, is
based on tissue irritability level and identified impairments
related to the patient’s movement problem. e stage of tissue
irritability, as defined in the STAR-Shoulder, is determined by
a combination of pain history, disability level, and examination
findings. is concept is related to the severity and irritability
131
of the condition as classically described by Maitland.
e
second and third levels of this classification, while presented
sequentially here, in practice, occur simultaneously during the
130
patient’s physical examination.
Novice clinicians and students may find it helpful to
assess potential contributing impairments after ruling in
and out hypothesized diagnoses. Evaluation of contributing
124
impairments to the movement problem
is typically a process
that distinguishes physical therapists from other healthcare
providers. Questions related to pain severity, including
completing a numeric pain rating scale and asking how
easily symptoms are provoked and abated, should help make
judgment on the overall irritability of the condition, regardless
of the diagnosis and predominant pain presentation. e level
of pain severity and irritability will inform the aggressiveness of
the examination and matched interventions selected for each
classification to address the patients underlying movement
problems.
Characteristics for each of the 3 stages of irritability (high,
132
medium, and low) have been previously described.
High
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19
Figure 6.
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e Staged Approach for Rehabilitation of Shoulder Disorders with
International Function Classification Categories*
Complaint of “Shoulder Symptom”
Level 1: Screening
History, basic physic al
examination, red or yellow flags
Appropriate for
physical therapy
Subacromial Pain Syndrome &
full-thickness rotator cuff tear:
shoulder pain & muscle
performance deficits
(1) Tissue irritability (Guides intensity of physical stress)
(2) Impairments (Guides specific intervention tactics)
High irritability &
identified impairments
*Adapted from McClure and Michener.
Appropriate for physical
therapy & referral
Level 2: Pathoanatomic
Diagnosis Specific Physical
Examination
Shoulder origin of
symptoms
Adhesive Capsulitis:
shoulder pain &
mobility deficits
Level 3: Rehabilitation Classification
Moderate irritability &
identified impairments
130
Nonshoulder origin of
Glenohumeral
Instability & SLAP:
shoulder pain & motor
control deficits
Low irritability &
identified impairments
irritability is characterized by high pain intensity (≥7/10),
constant night or rest pain, high disability level, and on clinical
examination pain that limits ROM, and typically a greater
limitation of active compared to passive motion. Moderate
irritability is characterized by moderate pain intensity (4-6/10)
that is intermittent at night or rest, moderate disability, and
examination findings of little discrepancy between passive and
active ROM with pain primarily at end-ranges. Low irritability
or night pain, minimal pain at end ROM with overpressure,
and active and passive ROM that is equal. e irritability
classification has demonstrated reliability and concurrent
validity by physical therapists clinicians.
133
Not appropriate for
physical therapy
symptoms
Level One: Screening
Red flags
Level 1 of the evaluation process
includes screening for red and yellow
flags to assist with evaluation and
physical therapy management decisions.
Red flags are signs and symptoms that
raise suspicion of serious underlying
pathology. If a serious pathology is
suspected, a clinical decision should
be made to refer the patient to an
appropriate healthcare practitioner.
Common medical red flags to consider
in a patient who presents with shoulder
pain are tumors (benign or malignant),
infection, visceral pathology, and
rheumatological conditions.
134
Other
red flags that may present as shoulder
pain include polymyalgia rheumatica
in patients over 60 years old, acute
long thoracic, spinal accessory, or
other nerve palsy, Parsonage-Turner
syndrome, or visceral causes that irritate
the mediastinal pleura pericardium
135
e importance of
Other
or diaphragm.
performing routine blood pressure
screenings in all patients as part of
the systems screen is also essential to
physical therapy practice.
136
In the
case of a traumatic onset of shoulder
pain, the need for imaging to rule
out fracture, dislocation, or acute fullthickness rotator cuff tear is discussed
later in the monograph.
A systematic evaluation of the
patient’s medical history, medication
use, and relevant family medical
history to determine the relative risk
of potential red flags contributing to
the pain presentation is essential. e
OSPRO-Review of Systems Tool is a validated standardized
screening tool used by physical therapists to identify medical
red flags in patients presenting to outpatient physical therapy
137
clinics.
e OSPRO-Review of Systems with 23-items
accurately identified 100% responders with potential red flags.
A shorter 10-item version accurately identified 94%.
137
In addition to screening for red flags, the medical history
can also be used to inform the prognosis for patients seeking
physical therapy intervention for a variety of conditions.
Another tool is the Charlson Comorbidity Index that includes
22 potential weighted health conditions (each rated 1 to 6)
used to derive a score that represents the severity of the medical
comorbidities.
138
Comorbidity burden has been proposed to
20
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Table 2.
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Key History and Physical Examination Findings for Common Pathoanatomic Diagnoses*
Diagnosis Positive Findings to Rule In Negative Findings to Rule Out
Subacromial pain
syndrome
Impingement signs (Neer, Hawkins, Jobe [Empty Can])
Painful arc
Significant loss of passive motion
Apprehension with instability tests
Pain with resisted external rotation
Positive long head of biceps tests
Substantial rotator
cuff tendon tear
Age >60
Lag signs
Weakness
Atrophy
Primary adhesive
capsulitis
Spontaneous progressive pain
Loss of motion in 2 or more planes & external rotation
most limited
Imaging for glenohumeral joint OA
Age <40 years
Normal passive glenohumeral joint
motion
Glenohumeral joint
instability
Age <40 with atraumatic onset
History of dislocation or subluxation
No history of dislocation or subluxation
Apprehension with instability tests
Apprehension test
Relocation test
Generalized or systemic laxity (≥5/9 Beighton scale)
SLAP lesion tests
Abbreviations: AC, acromioclavicular; OA, osteoarthritis; SLAP, superior labral anterior to posterior
*Adapted from McClure and Michener.
130
explain the impact of patient medical complication severity on
outcomes and used to risk-adjust patient-reported outcomes
data to compare these across various practice sites.
139
Of importance, the history and examination findings for
the subacromial pain syndrome category in the STAR-Shoulder
also include those that rule in a full-thickness rotator cuff tear
(weakness, pain, atrophy). ere is not a distinct category for
management of full-thickness rotator cuff tears, yet the clinical
pathway may differ for some patients with full-thickness tear.
For patients with an atraumatic full-thickness rotator cuff tear,
that may be indistinguishable from subacromial pain syndrome
on clinical examination, rehabilitation is considered the first
line of intervention.
140
However, if a traumatic full-thickness
rotator cuff tear diagnosis is hypothesized based on history
and clinical examination findings, a referral to an orthopaedic
shoulder surgeon and imaging is essential.
128
Delayed surgical
repair in the presence of an acute rotator cuff tear negatively
impacts patient outcomes.
141
Given the high prevalence of asymptomatic degenerative
rotator cuff tears,
142
older adults may have an acute injury to
a prior asymptomatic rotator cuff tear. e chronicity of a
rotator cuff tear can only be evaluated with MRI. Compared
to acute tears, chronic rotator cuff tears have evidence of
rotator cuff muscle atrophy and fat infiltration evaluated in
the sagittal oblique view on MRI, termed scapular Y-view
(Figure 7).
85
e American Academy of Orthopaedic Surgeons
Clinical Practice Guidelines for Rotator Cuff Injury states,
“Strong evidence supports that patient reported outcomes (PRO)
improve with physical therapy in symptomatic patients with full
thickness rotator cu tears. However, the rotator cu tear size,
muscle atrophy, and fatty inltration may progress over 5 to 10
years with non-operative management.”
140
us, it is prudent
to refer patients with a suspected traumatic rotator cuff tear
to a specialist for consultation and discussion of non-surgical
and surgical intervention options for the best short-term, and
long-term, patient outcomes. Readers are encouraged to keep
apprised of evolving evidence with several randomized placebocontrolled trials comparing rehabilitation to surgical repair for
the management of acute traumatic rotator cuff tears currently
being conducted.
143,144
Role of imaging
As previously discussed, as direct-care providers for patients
with musculoskeletal shoulder pain, it is essential for physical
therapists to identify when imaging is appropriate to rule out red
flags. In some practice environments, physical therapists have
imaging prescribing privileges. With the proliferation of physical
therapists as the primary entry provider for musculoskeletal
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21
Figure 7.
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Magnetic Resonance Imaging (T2 weighted) Sagittal Oblique Image illustrating the Scapular
Y-view
is view is performed to evaluate the rotator cuff
muscles. A, A healthy individual (IS, infraspinatus;
SC, subscapularis; SS, supraspinatus; TM, teres
minor). B, A patient with a chronic massive rotator
cuff tear involving SS and IS. Chronicity is shown
by the magnitude of SS and IS atrophy and fat
infiltration (arrow).
pain, it is important to understand the indications, safety, and
risks for the appropriate imaging modality for patients across a
variety of presentations. Physical therapists should be aware of
hypothesized diagnoses that require a change in care pathway,
such as immobilization with a fracture or surgical consult for
patients with an acute large rotator cuff tear, when considering
imaging referral.
e American College of Radiology has outlined
Appropriate Use Criteria based on best-available evidence for
use across a variety of patient presentations including traumatic
and atraumatic shoulder pain.
145,146
e suspected patient
presentations are presented as variants that recommend the
type of imaging when a particular pathology is hypothesized.
Radiographs are the first choice of imaging because they are
fast, safe, and effective in identifying many shoulder conditions.
In patients with a traumatic mechanism of injury, radiographs
are recommended to rule out fracture (the clavicle, scapula, or
proximal humerus), a dislocation, or other soft-tissue instability
(AC ligaments or capsulolabral complex) injuries.
145
Physical
therapists should ensure patients are referred for imaging
following a trauma to rule out these red flag hypothesized
diagnoses.
In patients with atraumatic etiology of shoulder pain,
hypothesized diagnoses such as calcific tendinopathy, rotator
cuff tear arthropathy, and osteolysis of the distal clavicle can
be detected with radiography.
147
For most atraumatic soft
tissue hypothesized diagnoses, non-surgical management is the
recommended care pathway.
128
erefore, physical therapists
can proceed without immediate referral for imaging. Regardless
of the mechanism of injury, radiography is recommended as
the first imaging modality used for most patients with shoulder
145,146
pain.
Standard radiographic imaging can vary widely, but
typically at least 2 orthogonal views are needed and 3 are
preferred. Following a trauma with a suspected shoulder fracture
or dislocation, shoulder radiographic imaging series include a
frontal view with a true anterior-to-posterior radiographic view
(Grashey projection) taken perpendicular to the GH joint.
Additionally, orthogonal views of either a Scapular Y-view
or an Axillary view are necessary (Figure 8). Without a view
orthogonal to the anterior-to-posterior view, lesions such as
posterior dislocations can be missed. e scapular Y or axillary
views can identify a compression fracture on the posterior aspect
of the humeral head, termed a Hill Sachs lesion, characteristic of
17
anterior GH joint instability.
In patients with atraumatic soft
tissue lesions, the radiographic series includes frontal views that
are anterior-to-posterior, instead of true anterior-to-posterior
views, in internal and external GH rotated positions. Findings
in these views that implicate rotator cuff soft tissue injury, such
as rotator cuff arthropathy, include a reduced acromiohumeral
distance or humeral subchondral cysts indicative of a chronic
large/massive rotator cuff tear.
Ultrasound imaging may be used in lieu of radiographs
for patients with atraumatic shoulder pain when hypothesized
diagnoses include rotator cuff injuries, adhesive capsulitis,
146
calcific tendinopathy, or a soft tissue mass.
Figure 9
illustrates evaluating the supraspinatus rotator cuff tendon in
cross-section (short axis) and longitudinal (long axis) views.
Ultrasound imaging technology enhancements have improved
Figure 8.
Radiographs of the Shoulder
A, True anterior-to-posterior (Grashey) view. B,
Axillary view. Arrow: A fracture of the anterior inferior
aspect of the glenoid rim following a dislocation
(Bony Bankart).
22
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Figure 9.
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Ultrasonography of the Rotator Cuff
Tendons
Long axis (coronal) view, left. Short axis (sagittal)
view of the supraspinatus (SS) and biceps long head
tendons (arrow), right. e humeral head (HH) is
hyperechoic (bright) curvilinear line at the bottom of
each image with the SS tendon as the next superficial
structure.
the diagnostic accuracy of detecting full-thickness rotator cuff
tear, that is now comparable to that of MRI.
148
If radiographs are not contributory to a diagnosis, then
MRI is recommended.
145,146
Magnetic resonance imaging is most
effective and considered the gold standard in detecting osseous
lesions, such as subtle fractures, erosive changes to the distal
clavicle, early avascular necrosis, and soft tissue abnormalities
of the glenoid labrum, rotator cuff, and biceps tendons, and
rotator cuff muscle atrophy and fat infiltration.
149
If the patient
presents with pain and substantial weakness following a trauma,
age influences the hypothesized red flags shoulder pathologies
that necessitate MRI following negative radiographs. In older
individuals, acute or acute on chronic traumatic large or
massive rotator cuff tears are common and should be suspected.
In younger patients, one may hypothesize a potential nondisplaced fracture of the greater tuberosity (Figure 10). In both
cases, initial radiographs may be negative, but further MRI
can clarify the diagnosis and is warranted because a change in
the care pathway
128
from physical therapy intervention would
be necessary if these conditions are confirmed. For other
hypothesized musculoskeletal soft tissue injuries, such as labral
tears, there is no change in the care pathway, with non-surgical
management recommended.
145
erefore, follow-up imaging
is only indicated as an initial consideration when red flag
diagnoses are suspected.
Additional advanced imaging is indicated primarily for
surgical considerations. e addition of a gadolinium-based
contrast agent injected into the GH joint allows for enhanced
joint visualization with magnetic resonance arthography
(MRA).
146
Magnetic resonance arthography is indicated for
hypothesized diagnoses such as atraumatic instability, a labral
tear, and smaller articular-sided rotator cuff tears when MRI is
Figure 10.
Coronal Oblique T2 Magnetic Reso-
nance Imaging
e image shows an intact supraspinatus tendon with
a greater tuberosity fracture.
inconclusive. Computed tomography of the shoulder is usually
reserved for evaluation of fracture/fracture-dislocation or for a
prosthetic joint.
150
Images from the axial, sagittal, and coronal
planes can be combined in 3-dimensional format to help
with assessment of severity of the shoulder condition and preoperative planning.
Overall, referral for imaging should be reserved for patients
in whom the care pathway would change based on the imaging
result. In patients with an onset of atraumatic shoulder pain
under the age of 50 years, radiographs rarely alter the diagnosis
or affect the management.
151
Immediate imaging should be
used to rule out red flags in patients who present with risk
factors and/or examination findings for serious pathology or in
patients following a trauma.
145,146
Imaging is also warranted in
patients who do not respond as expected with physical therapy
management, or other non-surgical interventions.
Yellow flags
Yellow flag screening is used to identify psychosocial risk
factors for development of prolonged disability following the
onset of musculoskeletal pain. If yellow flags are identified
in Level 1, the STAR-Shoulder suggests that delivery of
treatment interventions and patient education strategies be
accordingly adjusted.
130
A systematic evaluation of yellow flags
is recommended to identify patients at high-risk because the
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23
clinician’s ability to detect the presence of yellow flags such as
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depression or fear avoidance is suboptimal without the use of
152-154
a standardized tool.
e OSPRO-Yellow Flag Assessment
Tool is a 17-item standardized questionnaire that is able to
accurately identify yellow flags 85% of the time and estimates
multiple individual psychological questionnaire scores without
155
burdening the patient by completing each instrument.
e tool is designed to assess 9 domains including depressive
symptoms, anxiety, anger, fear-avoidance, kinesiophobia,
catastrophizing, self-efficacy, and pain acceptance.
Another tool designed specifically to stratify care to optimize
156
patient intervention outcomes is the Keele STarT MSK Tool.
Similar to the STarTBACK Tool for patients with low back
157
the STarT MSK Tool is used to identify intervention
pain,
referral pathways for patients with a variety of other common
musculoskeletal conditions. Responses to the questionnaire is
used to allocate patients into 1 of 3 prognostic risk categories
(low, medium, high) based on the likelihood of persistent pain,
disability, and poor treatment outcome. In a feasibility pilot
randomized trial, general practitioners who integrated the tool
and the matched treatment options prescribed less opioids for
pain management, used less musculoskeletal-related imaging,
and referred patients to physical therapy earlier than control
156
practitioners not using the tool.
Screening tools for yellow
flags that are designed for risk-stratification can further assist
physical therapists determine whether traditional physical
therapy management strategies are likely to yield a good
patient outcome or if other psychologically-informed treatment
approaches are warranted.
Level Two: Specic Examination and Classication
e STAR-Shoulder includes the physical therapy
examination and classification of shoulder pain in Level 2 of
the algorithm. After determining patient appropriateness for
physical therapy in Level 1, Level 2, the specific examination
and classification, should include (1) ruling in and out primary
competing hypothesized diagnoses, and (2) examining potential
impairments contributing to the movement dysfunction and
irritability stage.
Tests and measures
An examination of the shoulder includes tests and measures
used in an attempt to determine the painful tissues and identify
contributing impairments to the movement dysfunction.
Hypothesized diagnoses can include local nociceptive sources,
referred somatic pain, and neurogenic, vascular, or visceral
pain sources. e therapist should screen the regions above and
below the shoulder to rule out somatic referred or neuropathic
sources of shoulder pain. e screen also will allow the therapist
to look for potential contributing factors to the movement
158
problem while taking into account regional interdependence.
Active ROM and end-feel with overpressures of the cervical
spine, thoracic spine and, distally, the elbow, wrist, and hand are
included in the screening process. In addition to contributing
to the diagnostic process, an appreciation of potential joint
mobility (hyper/hypomobility), surrounding joint muscle
lengths, and neural mobility during the screening process
may also inform about key contributing local and regional
impairments.
Concordant sign
e movements or positions that reproduce the patient’s
primary shoulder complaint should be used as a concordant
sign. is provocative movement can then be reassessed after
modifying some aspect of the painful task or after performing
a treatment technique to determine if any changes took place.
For example, a patient may report pain with shoulder elevation,
which the therapist notices is performed with excessive scapular
anterior tilt. Shoulder elevation can then be repeated while the
therapist applies a manual correction to increase posterior tilt
of the scapula. If the patient reports a decrease in pain rating
of at least 2 points on the numeric pain rating scale with
manual correction, then the therapist is more confident that
interventions to address the scapular movement may improve
159,160
the patient’s symptoms.
e 2-point threshold is used as
the minimal clinically important difference (MCID) in patients
161
with shoulder pain.
Establishing a concordant sign, which
is regularly re-assessed within and between treatment sessions
is helpful in clinical reasoning to determine the contribution
of movement dysfunctions and the effectiveness of treatment
strategies.
Observation and inspection
Observation and inspection of the shoulder is the first step
in the examination process aimed at establishing a diagnosis as
well as potential contributing impairments of the movement
dysfunction. One may observe bony alignment, the patient’s
preferred resting posture and arm position, and willingness to
move during the interview and when the patient is removing a
coat or shirt. Following a trauma, it is necessary to examine bony
alignment to determine if separation of the AC joint and/or an
unreduced dislocation of the GH joint is present, for examples.
e importance of exposing the shoulder region to allow visual
inspection of the anatomical structures and observation of
shoulder/scapular movements during the examination of the
shoulder cannot be emphasized enough.
Direct visualization also allows for detection of red flags such
134
as signs of infection, edema, and ecchymosis.
Observation of
the patient’s posture should include looking at the rotator cuff
muscles (infraspinatus, supraspinatus) as well as the trapezius,
deltoid, biceps, triceps, and pectoralis major for signs of atrophy
associated with neurological involvement, disuse, or tendon
tear. A tear of the long head of the biceps tendon is common
in older adults presenting with a deformity in the lower
arm. Atrophy of the infraspinatus and supraspinatus may be
indicative of a chronic rotator cuff tendon tear in older adults,
24
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and in younger adults a neurogenic cause (eg, suprascapular
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neuropathy) may be a more likely cause. Common in overhead
athletes, suprascapular neuropathy can occur with compression
at the spinoglenoid notch associated with a paralabral cyst and
162
affecting only the infraspinatus.
Alternatively, compression or
entrapment along the suprascapular notch would affect both the
supraspinatus and infraspinatus. Repetitive dynamic movements
162
of overhead athletics are considered in the etiology.
Specific
to patients referred following a shoulder surgical procedure,
an assessment of incisions is essential to screen for healing and
any signs of infection. Findings such as these could be missed
without close observation.
Postural findings should also be noted, yet the relationship
163,164
to shoulder pain should not be readily assumed.
Findings
from the observation of resting posture should be interpreted in
function of the rest of the clinical examination and symptom
reproduction. For example, increased thoracic spine kyphosis is
a contributing impairment associated with a movement problem
165
of limited humeral elevation ROM.
However, if the patient
who presents with excessive thoracic kyphosis is able to fully
extend the thoracic spine after being cued or during shoulder
elevation, then thoracic spine alignment may not be a potential
contributing impairment for this patient, especially if correction
of posture does not affect the concordant signs discussed above.
us, while posture alone has limited utility in the clinical
reasoning process, it may provide meaningful information
when taken in the context of the overall examination findings.
Scapular position
ere are approximately 20 clinical assessment methods
of static scapular posture with established psychometric
166,167
properties.
the scapula suggests a potential spinal accessory nerve injury
Excessive downward rotation and depression of
134
or AC joint separation (Type III injury), particularly when
accompanied by a step deformity. It can also suggest potential
impairments or movement dysfunction. Such findings should
prompt a thorough evaluation of scapular muscle length and
strength. Mild asymmetry in scapular posture and movement
(depression/protraction/elevation) is common and, in itself, does
168
not implicate pathology or a movement problem.
Evaluation
methods for asymmetric scapular position or movement lack
166
validity.
While the assessment of static scapular position using
a digital inclinometer with the arm at rest and in positions of
60°, 90°, and 120° of elevation is reliable and has demonstrated
166
concurrent validity,
static assessment of scapular position
should not be used to infer dynamic impairments or relevance to
the movement problem. Dynamic scapular motion is typically
assessed during shoulder active ROM examination discussed
later in this monograph.
Cervical and neurological screen
e cervical spine should be screened with active ROM and
overpressures in all cardinal planes of motion. An emphasis on
lower cervical spine motion can be used to rule out contributions
of the cervical spine to the patient’s concordant symptom.
When neuropathic pain is hypothesized, a neurological screen,
neural mobility, and tests for cervical radiculopathy should be
conducted as potential secondary diagnoses to primary shoulder
pain presentation. e modified painDETECT questionnaire
for the shoulder is reliable and sensitive to discriminate
169
nociceptive from neuropathic pain.
It consists of 12 items,
in 4 components, range of score from -1 to 38, asking about
neuropathic pain symptoms experienced in the right or left
shoulder over the past week. A score of 12 or greater suggests
169
a predominant neuropathic pain presentation.
Interventions
for patients with a neuropathic pain presentation may include
neural mobilization and/or interventions to target the source of
neuropathic pain (ie, cervical spine).
If cervical motion reproduces the concordant shoulder
pain, a radiculopathy or referred somatic pain from lower facet
joints (among other cervical structures) should be considered
and a comprehensive cervical examination and upper extremity
neurological screen be performed. e presence of 3 or more
of the 4 following examination findings would suggest cervical
radiculopathy (same side cervical rotation ROM of less than
60°, a positive median nerve upper limb neurodynamic test,
relief of symptoms with cervical distraction test, and a positive
Spurling’s test) with a positive likelihood ratio [+LR] of 6.1; the
170
negative likelihood ratio [-LR] is 0.65).
An upper extremity neurological screen that includes
deep tendon reflexes, myotome strength, and dermatomal
examination with static cutaneous sensation is important in all
patients, beyond those with a positive cervical screen. Because
the shoulder is innervated by C5 and C6 nerve roots and
corresponding peripheral nerves (subscapular, supraspinatus,
axillary), shoulder pain is characteristically located below the
106,107
acromion in the deltoid region.
Pain from the AC joint
is located on the superior aspect of the shoulder in a C4
106,107
distribution and is more focal.
When symptoms are below the elbow, proximal to the
AC joint, or in the periscapular region, a neurological screen
is necessary. When the patient presents with complaints of
numbness, tingling, paresthesia, or weakness indicative of
possible neurological involvement, a neurological examination
starting in the area of the chief complaint is indicated. Lastly,
when the patient presents with patterns of weakness beyond the
deltoid or rotator cuff, further examination for potential nerve
root or peripheral nerve involvement should include an upper
extremity neurological exam.
Concerns for upper motor nerve lesions such as myelopathy
are heightened in older individuals particularly with findings
of heightened reflexes, symptoms into the lower extremities,
171
or history of falls.
Hoffman and clonus testing are indicated
when hyperreflexia or other upper motor neuron lesion is
hypothesized. Other neurological issues including ParsonageTurner syndrome, acute nerve palsy, thoracic outlet, or brachial
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25
plexopathy should also be on the hypothesized diagnosis list with
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172
symptoms of weakness beyond the shoulder.
With acute nerve
palsy involving either the spinal accessory (cranial nerve VI) or
long thoracic (C5-7) nerves, the primary subjective complaint
may be shoulder pain that remains following an acute pain in
173
the shoulder girdle lasting 10 to 14 days.
e key finding is
scapular winging and weakness with muscle testing. A thorough
examination follows any suspected findings originating outside
of typical musculoskeletal shoulder patterns.
Active range of motion
Active shoulder ROM in all planes should be assessed
within pain severity and irritability tolerance and post-operative
guidelines with limitations documented with goniometric
measures. Modifications to reduce the risk of recurrence in
patients following an acute dislocation and within surgical
post-operative ROM guidelines should be made. e quality of
the movement should be observed, and symptom reproduction
should be noted. Combined motions of posterior reach (IR,
extension, adduction) and hand behind the head (ER, flexion,
and abduction) reaching down the spine can be included to
assess function. In patients considered to have low pain severity
and irritability, overpressure may be necessary to reproduce
concordant shoulder pain. Clinical relevance of active motion
limitations may be interpreted with a comparison of goniometric
measures bilaterally and to established normative values.
Limitations in active motion should be compared to passive
joint mobility assessments to rule in and out underlying joint
174
versus extra-articular diagnostic hypotheses
and contributing
e therapist should observe scapular motions to inform
its relative contribution to shoulder active motion as well
as the quality of scapular motion. An observational method
with established reliability and validity to identify abnormal
175,176
motion is the scapular dyskinesis test.
e therapist
observes scapular motion, each side independently (and not
relative to the contralateral side), during arm elevation with
light weights, looking for signs of dysrhythmia or winging.
e ability to reliably classify different types of dysfunction,
(eg, medial border winging, inferior angle winging, hiking) has
not been consistently demonstrated with clinical observation
assessments.
101,175,177,178
erefore, simplified dichotomous
options like present (obvious) or absent (subtle/normal)
176
have been proposed.
Obvious scapular winging during
dynamic shoulder movements can either inform a hypothesis
of impairments related to the movement problem or further
inform a diagnosis.
Scapular dyskinesis is not a pathoanatomic diagnosis. It
is a movement impairment that may or may not be related to
the patient’s shoulder pain given its prevalence in asymptomatic
168
individuals.
However, observed patterns of dyskinesis may
inform examination of additional underlying impairments to
the movement problem. For example, excessive scapular motion
in a pattern of hiking or increased upward rotation and posterior
102
tilt is consistent with GH joint hypomobility.
In contrast,
excessive medial border or inferior angle winging during
elevation in the mid-range of motion or with resisted elevation
at 90° may be a significant finding that leads the therapist to
hypothesize scapular upward rotators weakness (serratus anterior
and lower trapezius) or movement coordination impairment.
With obvious dyskinesis, weakness should not be assumed
as the cause. Examination of the middle and lower trapezius
and serratus anterior muscle strength is indicated. For patients
with obvious winging (Figure 11), the therapist must consider
the potential for long thoracic or spinal accessory nerve injury,
either (idiopathic palsy) or with a related plausible mechanism
of injury (neuropraxia).
92
Patients with dyskinesis and
substantial weakness, manual muscle testing grade less than fair
(3/5), or progressive weakness should be referred for diagnostic
electromyography (EMG) and nerve conduction velocity
testing to rule out neurological involvement. Further utility
of clinical observation tests to identify dyskinesis is unclear
given the challenge of validity as it relates to shoulder pain and
improvements in pain and disability that may be independent
of normalizing scapular motion.
168,179
In contrast to observation of movement, several symptom
of scapular motion or position to the patient’s shoulder
159,180-182
pain.
With these tests, the examiner manually alters the
position or movement of the scapula or thoracic spine during
shoulder elevation (or other) movement and compares the
symptom severity between unassisted and assisted/modified
positions. e scapular assistance test is performed by manually
inducing scapula upward rotation and posterior tilt during
Figure 11.
Obvious Scapular Winging
Observed during active humeral flexion holding
3-pound weights
26
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active shoulder elevation (abduction and/or flexion) (Figure 12;
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180
Supplementary online Video 1).
e test has demonstrated
acceptable inter-rater reliability in patients with shoulder
182
Similarly, the scapular reposition test is performed by the
pain.
therapist manually inducing scapular posterior tilt concurrent
with the patient being tested with an isometric empty or full
can resisted shoulder elevation test (Supplementary online
183
Video 2).
A positive response is defined as a reduction in
symptoms by 2 or more points, on a 0-10 pain scale, when
scapular manual assistance is applied. If either test is positive,
impairments related to scapular movement or position should
be evaluated as potential contributing factors to the movement
184
problem. Reduced scapular posterior tilt
185
pectoralis minor muscle length
are impairments related
and decreased
to a positive scapular assistance test – supporting the need to
provide interventions to increase the flexibility of the pectoralis
minor and scapular movement through exercises or soft tissue
mobilization techniques. However, individuals may vary in the
contributing impairments such as strength or motor control,
related to a positive scapular assistance test. A positive scapular
assistance test has been shown to be predictive of a favorable
outcome with physical therapy management for patients with
shoulder pain, possibly indicating a peripheral nociceptive pain
source with contribution of movement relating to symptoms.
Figure 12.
Scapular Assistance Test
186
e test is performed by manually assisting the
scapula into upward rotation and posterior tilt as the
patient elevates both arms. A reduction in pain by 2
points (0-10 pain scale) with assistance compared to
unassisted condition is a positive result.
Supplementary Online Video 1
https://www.orthoptlearn.org/mod/vimeo/view.php?id=693
Supplementary Online Video 2
https://www.orthoptlearn.org/mod/vimeo/view.php?id=694
Palpation
Palpation of the shoulder may help delineate AC joint pain
and pain from other superficial anterior structures from other
shoulder nociceptive sources. Palpation of the bony structures
along the clavicle, acromion, scapula, and humerus can help
with determination of potential bony injuries such as fractures
or step deformity with AC joint sprains. Palpation of the
musculature may identify atrophy, hypertrophy, hypertonicity,
and additional sources of muscular nociceptive drivers. Any
findings of pain or tenderness that appears to be non-anatomic
for patterns characteristic of shoulder disorders suggestive of
nociplastic pain, such as hyperalgesia or allodynia, should be
112
noted.
In patients with a traumatic mechanism of injury
or those who have been immobilized for any time period, an
appreciation of muscle adaptations and regional areas of soft
tissue mobility should also be considered. Infraspinatus trigger
points are common in patients with shoulder pain.
concept of trigger points has been challenged,
187
While the
188
interventions
such as dry needling and manual soft tissue treatments that
address muscular nociception or somatic referred shoulder pain
may serve as adjuncts to exercise as evidence-based care.
189,190
Passive joint mobility
Passive joint motion assessment is used during an
examination to determine joint mobility to either rule in
or out hypothesized diagnoses (eg, adhesive capsulitis) or
a contributing impairment to the movement problem (eg,
posterior shoulder tightness). All planes of motion can be
assessed with and without stabilizing the scapula to inform the
potential source of mobility deficit as either isolated to the GH
joint or not. Physiological motion can be reliably assessed with
a goniometer or inclinometer.
191
With passive joint assessments,
an appreciation of when the first point of resistance (R1) and
end point of motion (R2) occurs relative to the onset of pain
and change in pain severity is essential.
131
Similar to passive physiological motion assessments,
accessory joint mobility tests are used to further evaluate
an impairment in motion.
131
Assessment and comparison
bilaterally is necessary to determine the clinical relevance of
limitations. Limitations in accessory motion can be related to
pain, joint capsular tissues, surrounding musculature, or bone
adaptations. e end-feel, in addition to inform on the nature
of the resistance to motion, also assists in determining the level
of irritability of the condition. is information can be used
to guide the selection of additional tests and measures and
appropriately match initial interventions.
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Flexibility of selected portions of the soft tissues surrounding
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the GH joint can be assessed with passive physiological motion
and associated end-feels. e superior-anterior GH joint soft
tissues can be assessed with passive shoulder adduction at least to
neutral combined with shoulder extension or flexion motions.
Flexibility of the superior, middle, and inferior aspects of the
anterior GH joint can be inferred from passive physiological
motion in shoulder ER with the humerus at the side, 45°, and
90° of abduction, respectively (Supplementary online Video
192
3).
flexion has also been used to assess posterior shoulder tightness
attributed to soft tissues including deltoid, teres minor, or
193
latissimus dorsi muscles.
Measurement of 15° from the vertical
while the patient is supine and scapula stabilized is considered
normal. Clinicians should also take into consideration that
horizontal adduction assessment may be influenced by humeral
retrotorsion as well rather than just soft tissue length.
204
Supplementary Online Video 5
https://www.orthoptlearn.org/mod/vimeo/view.php?id=725
Supplementary Online Video 3
https://www.orthoptlearn.org/mod/vimeo/view.php?id=695
ere are several methods to evaluate posterior GH joint
capsule and soft tissue tightness including shoulder horizontal
adduction at 90° elevation (Supplementary online Video
193
4),
shoulder IR in low flexion (60° of shoulder flexion),
194
and shoulder IR at 90° scapular abduction. is last assessment
method needs to be interpreted within the context of
comparison with the non-dominant side and the total arc of
motion concept.
195
A surgically shortened posterior GH joint
capsule has been shown to increase superior migration of the
humeral head during passive humeral elevation in a cadaveric
196
model.
development of SLAP lesions,
anterior instability, and subacromial pain syndrome,
is mechanism is considered to contribute to
197
internal impingement,
199
198
and
would therefore be considered a contributing impairment to the
movement dysfunction in patients with shoulder pain.
Supplementary Online Video 4
https://www.orthoptlearn.org/mod/vimeo/view.php?id=698
Both bone (eg, humeral retrotorsion/retroversion) and
soft tissue adaptations occur with repetitive stress of overhead
athletics
IR ROM and/or horizontal adduction.
200
that result in increase shoulder ER ROM and decrease
201
A loss of passive IR
motion alone may not be pathologic and should be assessed
in the context of the total arc of motion (Supplementary
online Video 5).
195
e total arc of motion, defined as the
amount of internal plus external GH rotation assessed at 90° of
shoulder abduction with the scapula stabilized,
the adaptative shift in motion
4
and should equal the combined
202
accounts for
measure of the contralateral shoulder (typically between 165180°). Pathologic glenohumeral internal rotation deficit
(GIRD) occurs when the loss of IR exceeds the increase in ER
noted by either a loss in total arc of motion of >5° or a loss of
IR ROM of 10-25° compared to the non-dominant shoulder,
and is considered a risk factor for injury in overhead athletes.
203
Horizontal adduction with the arm positioned in 90° of
Pathological GIRD has been attributed in part to posterior
195
capsular restriction.
But, examination methods of posterior
capsule length performed in a cadaveric study and validated
in overhead athletes indicate that rather than IR at 90° of
abduction, IR in a low angle of flexion (60°) produce the most
194,205
strain on the posterior capsule.
a potential impairment, contributing to movement dysfunction,
that can be resolved with mobility interventions.
is should be evaluated as
206
Lastly, passive accessory joint mobility assessment may
help determine the source of limited physiological motion,
131
as possibly intra- versus extra-articular.
Accessory motion
should be graded as either hypomobility, hypermobility, or
207
normal mobility given limited reliability with other scales.
erapists should appreciate the amount of motion available
relative to that of the uninvolved shoulder as well as the painresistance sequence, which is used to determine the level of
irritability. Accessory motion should be assessed for the GH
and AC joints and may also be assessed for the scapulothoracic
and SC joints, as clinical reasoning dictates. is assessment
may help determine related contributing impairments or
additional sources of concordant symptoms. It is imperative
to assess passive accessory joint mobility of the cervical and
thoracic spine as the regional interdependence concept suggests
158
potential relevance.
Muscle performance
Shoulder muscle performance can be evaluated to either
confirm a diagnostic hypothesis related to contractile tissues or
identify potential contributing impairments to the movement
dysfunction. While it is impossible to isolate particular muscles
with strength tests at the shoulder due to contributions of many
primary movers and stabilizers, positions that best maximize
isometric muscle activity of individual rotator cuff and scapular
208,209
muscles have been identified using EMG.
ese resemble
the positions for special tests (lag signs) proposed to identify the
location of various full-thickness rotator cuff tears, which will
174
be discussed later in the monograph.
Objective measures are necessary to detect subtle weakness
and determine change associated with interventions. Using
a hand-held dynamometer (HHD) is recommended to
measure isometric strength when at least fair strength (full
28
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