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movement against gravity) is present. While isokinetic testing
https://t.me/med1917
is considered the gold standard for strength assessment, a
HHD has advantages for clinic use including cost, portability,
and time efficiency compared to isokinetic devices. It allows
for assessment of maximal force output efficiently and is
more accurate and precise than use of manual muscle tests in
210
patients with shoulder pathology.
Furthermore, shoulder
strength assessment in individuals considered “normal” with
manual muscle tests have shown deficits up to 20% when re-
211
assessed using a HHD.
e HHD can be placed at the distal
humerus (ulnar or radial styloid) depending on the test being
performed. Isometric testing in any plane can be performed
with the shoulder in neutral position and the patient in a seated
or standing position. If indicated, isometric tests in elevation to
90° (flexion, abduction, scapular plane abduction), and external
and IR at 90° abduction can also be performed in the sitting,
supine, or prone positions with or without the distal humerus
manually stabilized by the therapist.
A ‘‘make’’ test with the patient gradually increasing force
against resistance of the therapist or a stationary object yields a
more reliable measure of maximal force when using a HHD.
212
Evaluation of eccentric strength of the external rotators with a
HHD has also demonstrated good reliability and concurrent
213
validity compared to isokinetic testing.
When using a HHD,
a change in strength at the shoulder of more than 15% is needed
to be considered a real change, (minimum detectable change
214
[MDC]) and not due to measurement error.
When pain is
present, strength tests have limited validity due to potential for
pain to limit generating maximal effort. However, a finding of
pain can inform clinical reasoning for hypothesized diagnoses
and also could be used as a concordant sign, especially if
combined with force value at which pain first occurred (another
advantage of using a HHD for strength testing).
A balance of the force couple consisting of the anterior
and posterior GH joint musculature, determined with muscle
force using ER to IR strength ratios, is an important goal for
rehabilitation of shoulder injuries and in pre-participation
215
evaluations of athletes.
is considered normal, but may vary across populations.
Ratios of IR to ER of 0.6 or greater
215,216
Weakness in ER is a risk factor for upper extremity injury in
overhead athletics.
217
Special tests
Special tests may assist in categorizing patients with a
pathoanatomic diagnosis and the shoulder rehabilitation
classification. ere is concern regarding the continued use
of special tests given the lack of validity to isolate painful
structures in the shoulder and the negative impact of labeling
a pathoanatomic structure with patients, especially considering
that the rehabilitation interventions often do not differ for
many diagnoses.
71,118,122,123,218
ere are 3 major pathoanatomic
and regional pain source categories within the STAR-Shoulder
classification: (1) subacromial pain syndrome, (2) adhesive
capsulitis, and (3) GH joint instability. A fourth option is: other
130
category.
Pathoanatomic diagnoses related to the subacromial pain
syndrome category can include many structures/conditions:
rotator cuff tendinopathy, partial- and full-thickness rotator
cuff tendon tears, bicipital tendinopathy, bursitis, secondary
instability, and SLAP lesions. Pathoanatomic diagnoses in the
GH joint instability category include traumatic subluxations
and dislocations (anterior or posterior) and atraumatic
instability (unidirectional or multidirectional). Some tests to
rule in SLAP lesions
219
also are used for anterior instability
and biceps tendinopathy, which illustrates the intimate
anatomical relationship of the biceps and superior capsulolabral
complex.
119
Given the limited diagnostic value of single tests,
it is recommended to use combinations of tests to improve
diagnostic accuracy.
120,220,221
Subacromial pain syndrome
Subacromial impingement is a term used to infer a
mechanism related to compression of the rotator cuff tendons
as the pain source in the subacromial space,
61
from either
anatomical variants (acromial shape) or functional impairments,
eg, abnormal scapular or humeral motion, that reduce the
subacromial space.
222
e use of this term has recently been
discouraged given the: lack of evidence linking mechanical
impingement of the rotator cuff with shoulder symptoms
71
;
evidence refuting the effectiveness of acromioplasty compared
to sham surgery
is equally effective as surgery.
223,224
; and strong evidence that suggests exercise
67,225
us the term subacromial
pain syndrome, and related synonyms are alternatives proposed
that do not implicate the rotator cuff or other anatomical
structure and mechanism of injury.
118
Single tests are not diagnostic of subacromial pain
syndrome.
119
But, any combination of 3 positive findings from
the following 5 tests have been advocated to rule in subacromial
pain syndrome: Neer sign (Supplementary online Video 6),
Hawkins sign (Supplementary online Video 7), Jobe (Empty
Can) test (Supplementary online Video 8), a painful arc,
and pain/weakness with resisted shoulder ER.
3 tests are positive there is some confidence for the diagnosis
of subacromial pain syndrome (+LR of 2.93; -LR of 0.30).
220,226
When any
226
When the positive examination findings are specifically the
Hawkins sign, a painful arc, and pain/weakness with resisted
Supplementary Online Video 6
https://www.orthoptlearn.org/mod/vimeo/view.php?id=726
Supplementary Online Video 7
https://www.orthoptlearn.org/mod/vimeo/view.php?id=727
Supplementary Online Video 8
https://www.orthoptlearn.org/mod/vimeo/view.php?id=728
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.
29
shoulder ER, the ability to rule in subacromial pain syndrome
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is the greatest (+LR of 10.56).
220
When all 3 are negative, it
is highly likely that subacromial pain syndrome is not the
diagnosis (-LR of 0.17).
Full-thickness rotator cu tears
A clinical examination cannot distinguish partial thickness
and small full-thickness rotator cuff tears from the diagnosis of
subacromial pain syndrome.
220,227
However, the care pathway of
shoulder pain diff ers for patients with an acute full-thickness
tendon tear, making accurate diagnosis clinically important.
Systematic reviews suggest a high-risk of bias and low
overall quality for many diagnostic accuracy studies, making
interpretation of the related literature diffi cult.
119,228
Factors such
as an older age (>65 years) and pain at night, combined with the
examination fi nding of weakness in ER, substantially increase
the probability of a rotator cuff tear (combined specifi city of
94.4%, positive predictive value of 93.1% and +LR of 9.8).
229
Lag signs are tests designed to capitalize on identifying
discrepancies between active and passive shoulder motion, also
considered strength loss, to rule in/out larger full-thickness
rotator cuff tears.
174
As originally proposed, the ER lag sign
with the arm at the side and elevated to 90° are designed to
test for larger full-thickness tears involving the infraspinatus
tendon, and the drop arm sign is for larger tears involving the
supraspinatus tendon (Table 3).
174
Diagnostic accuracy studies for full-thickness rotator cuff
tears typically use intra-operative fi ndings or imaging as the
reference standard and are conducted in patients seeking surgical
Table 3.
Special Tests to Diagnose Superior to Posterior Tendon Full- ickness Rotator Cuff Tears
Test Name Description of the Test Tendon SN SP +LR -LR
Drop arm With the patient sitting or standing, the
shoulder is placed in 90° abduction. e
examiner removes arm support. A positive
Supraspinatus
and
infraspinatus
test is if the arm drops.
Full-thickness
unspecifi ed
External rotation lag sign
(at side)
With the patient’s elbow at 90° of fl exion,
the examiner passively moves the arm to
Infraspinatus
20° of scapular plane abduction and near
maximal external rotation (5° short). e
patient is then asked to retain this position
Infraspinatus
for 10 seconds as the examiner releases the
force maintaining the shoulder in external
rotation while maintaining support at the
elbow. e test is positive if the patient is
unable to hold the shoulder in end-range
external rotation.
External rotation lag sign
at 90° (also called
Hornblower’s sign)
With the patient’s elbow fl exed 90°, the
examiner passively elevates the arm to 90° in
the scapular plane. e examiner externally
Infraspinatus
rotates the shoulder, then releases the
forearm while maintaining support through
Teres minor
the elbow. e test is positive if the patient
is unable to hold the shoulder in end-range
external rotation.
Abbreviations: -LR, negative likelihood ratio; +LR, positive likelihood ratio; SN, sensitivity; SP, specifi city
231
230
44 98 26.1 0.6
174
10 100 5 0.92
174
69 98 35 0.3
230
98 98 49 0.02
174
21 92 2.6 0.86
95 92 12 0.05
30
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.
intervention for a rotator cuff tear. In the context of low overall
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study quality, the larger and more chronic the rotator cuff tear,
the more likely the exam results are able to rule in a full-thickness
tear. e ER lag sign has high diagnostic accuracy to rule in and
out larger tears that involve the teres minor,
(63%) with smaller tears involving the infraspinatus tendon.
230
but is less sensitive
174
erefore, the ER lag sign at 90° of elevation or hornblower’s
sign can be used to rule in and out large/massive rotator cuff
tears involving the teres minor.
174,230
Lastly, the drop arm sign
is highly specifi c to rule in a supraspinatus and infraspinatus
tear when the test is positive, but has limited ability to rule out
rotator cuff tear when it is negative.
174,231
Common tests intended to detect subscapularis tendon
232
tears include the IR lag sign, lift off ,
234
tests (Table 4). e lift off test may be limited due to pain
hug
belly press,
233
and bear
reaching behind the back, but the belly press test overcomes
this limitation by internally rotating against the abdomen while
abducting the humerus. A patient with a positive belly press
test is shown in Figure 13. Because the pectoralis major and
latissimus dorsi also contribute to IR strength, positions that
attempt to minimize these contributions are used. e lift off ,
belly press, and bear hug tests have low quality evidence that
suggest these are best used to rule in subscapularis tears when
positive result is found.
174,234
Table 4.
Special Tests to Diagnose Full-thickness Rotator Cuff Tears of the Subscapularis
Test Name Description of the Test SN SP +LR -LR
Internal rotation lag sign
Lift off test
Belly press test
174,234
e therapist passively places the patient’s hand of the tested
shoulder behind the lumbar region (hand behind back).
e hand is then passively lifted away from the lumbar
spine, and then passive support is slowly released. A positive
test is when the patient is unable to maintain the position
unsupported.
Performed by placing the hand of the aff ected shoulder on
the back (lumbar spine) and asking the patient to internally
rotate the arm to lift the hand posteriorly off of the back.
e test is considered positive if the patient is unable to lift
the arm posteriorly off of the back or the action is performed
by extending the elbow or the shoulder.
Performed with the arm at the side and the elbow fl exed
to 90°, by having the patient press the palm into their
abdomen by internally rotating the shoulder. A positive test
result is the inability to attain the position of the arm in
abduction, indicated by the elbow staying posterior to the
thorax.
97 96 24 0.03
62 98 31 0.39
40 98 20 0.61
Bear hug test
Abbreviations: -LR, negative likelihood ratio; +LR, positive likelihood ratio; SN, sensitivity; SP, specifi city
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.
Performed by passively positioning the shoulder in 90° of
fl exion as the patient internally rotates to touch the top of
the opposite shoulder. e patient tries to hold the starting
position by means of resisted internal rotation as the
examiner tries to pull the patient’s hand from the shoulder
with an external rotation force applied perpendicular to the
forearm.
31
60 92 7.5 0.32
Figure 13.
https://t.me/med1917
Belly Press Test
Figure 14.
A B C
Anterior Instability Test Cluster
A positive test is indicated when the
patient is unable to hold the elbow away
from side while internally rotating and
pressing palm of the hand against the
abdomen, as seen in the patient’s left
upper extremity.
A, Anterior apprehension. Palpation of the glenohumeral joint as
the humerus is passively externally rotated. B, Relocation. Posterior
translation force provided at the anterior aspect of the proximal humerus
and reassessing symptom response. C, Release. Posterior translation force
on the humerus is suddenly released.
Instability
Diagnostic accuracy studies for tests designed to diagnose
shoulder instability have been conducted primarily in patients
seeking orthopaedic surgeon consultation using a reference
standard of imaging or intra-articular findings during
arthroscopy. While tests that require the examiner to judge the
magnitude of translation have been used to diagnose shoulder
instability, these typically only test joint laxity. Tests aimed
to reproduce symptoms of apprehension or pain have better
psychometric properties. e apprehension (Supplementary
online Video 9), relocation (Supplementary online Video
10), and anterior release (surprise) (Supplementary online
Video 11) tests are a sequential test cluster used to diagnose
anterior instability (Figure 14). With both the apprehension
and relocation tests, a positive comparable sign of apprehension
improves both the sensitivity and specificity compared to using
pain reproduction alone (Table 5).
221
e combination of
anterior apprehension and relocation test has the best diagnostic
accuracy to rule in and out anterior instability (sensitivity 81%,
Supplementary Online Video 9
https://www.orthoptlearn.org/mod/vimeo/view.php?id=729
Supplementary Online Video 10
https://www.orthoptlearn.org/mod/vimeo/view.php?id=730
specificity 98%, +LR 39.7, -LR 0.19).
221
Table 5 provides
diagnostic accuracy of anterior instability tests using either pain
or apprehension as a positive result.
221,235
Posterior shoulder pain may be related to internal
impingement or posterior instability. e anterior apprehension
test may be a concordant sign of pain located in the posterior
aspect of the shoulder, consistent with internal impingement
usually in overhead athletes. Athletes with internal impingement
have a gradual onset of symptoms and pain noted in the cocking
position of the throwing motion.
236
Internal impingement of
the articular side of the supraspinatus and/or infraspinatus can
occur with shoulder ER and abduction, and further exacerbated
with shoulder hyperabduction,
position of throwing in the overhead athlete.
237
characteristic of the cocking
238
In patients
with posterior internal impingement sign, pain is reproduced
posteriorly in the shoulder with the apprehension test
reduced or abolished with the relocation test.
238
236
and
Patients with posterior instability typically complain of
pain with posteriorly directed forces at the GH joint when the
shoulder is in flexion and horizontal adduction. e posterior
apprehension test (Figure 15; Supplementary online Video
12) assesses for posterior GH joint instability using this position
and has psychometric properties (Table 5) suggesting it can be
used to rule in, but not to effectively rule out the diagnosis of
posterior instability.
239
Supplementary Online Video 11
https://www.orthoptlearn.org/mod/vimeo/view.php?id=731
Supplementary Online Video 12
https://www.orthoptlearn.org/mod/vimeo/view.php?id=732
Academy of Orthopaedic Physical erapy, APTA.
32
© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
For personal use only. No other uses without permission.
Table 5.
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Diagnostic Accuracy of Instability Tests
221,235,239,240
Direction Test Test Description Result SN SP + LR - LR
Anterior
instability
Anterior
apprehension
e patient is supine and the therapist
passively brings the shoulder to 90° of
Pain 50 56 1.1 0.89
abduction and then slowly externally
rotate the shoulder. A positive test is the
reproduction of pain or apprehension,
Apprehension 72 96 20.2 0.29
or both.
Relocation e apprehension test is repeated while
Pain 30 90 10.4 0.20
the therapist provides a posteriorly
directed force to the anterior aspect
of the proximal humerus. e test
is only relevant when the anterior
apprehension test is positive. A
Apprehension 81 92 3.0 0.77
positive test is when the pain and/
or apprehension felt with the
apprehension test is significantly
reduced or eliminated.
Anterior release
(also called
Surprise)
e test is as for the relocation test
above, but at the end of shoulder
external rotation, the therapist quickly
Pain or
apprehension
removes the posteriorly directed
stabilizing force. A positive test is when
pain or apprehension is reproduced.
Posterior
instability
Posterior
apprehension
With the patient supine and the elbow
flexed to 90°, the shoulder is flexed to
Apprehension 19 99 19 0.82
90° and adducted. e therapist applies
a posteriorly directed force via the long
axis of the humerus.
Inferior
instability
Hyper-abduction
test
e therapist stands behind the patient
and applies an inferiorly directed force
on the scapula and passively abducts
the shoulder to 90° with the elbow
Apprehension or
increased laxity
with >105° of
abduction
flexed.
Abbreviations: -LR, negative likelihood ratio; +LR, positive likelihood ratio; SN, sensitivity; SP, specificity
64 99 58.6 0.37
67 89 6 0.37
Inferior instability is typically present with atraumatic
instability and those with overall generalized laxity. Clinicians
heavily rely on laxity noted with the sulcus sign to rule in
inferior instability and MDI. However, the sulcus test is a test
for laxity and lacks diagnostic value. Inferior instability can
more accurately be evaluated with the hyperabduction test
(Table 5). While increased laxity with >105° of abduction with
the scapula stabilized can be noted with passive ROM testing
(passive ROM with stabilization Supplementary online Video
13), apprehension is considered a positive result. is test is
best used to rule in inferior instability.
diagnostic criteria for MDI, but at least 2 directions of positive
tests (anterior apprehension, posterior apprehension, and
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For personal use only. No other uses without permission.
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240
ere are no consistent
hyperabduction) and the presence of a positive Beighton score
120
are highly suggestive of MDI.
Varying cut points for a positive
Beighton score have been described, however, a score of 5/9 as
a cut off for adolescents and adults (with a relevant history) and
6/9 for pre-pubescent groups have been advocated.
Labral tears and SLAP lesions
ere are many tests proposed to diagnose labral tears
and more specifically a SLAP lesion. Initially published high
diagnostic accuracy data for proposed tests for SLAP lesions
Supplementary Online Video 13
https://www.orthoptlearn.org/mod/vimeo/view.php?id=733
33
241
Figure 15.
https://t.me/med1917
Posterior Apprehension Test
A posteriorly directed force is applied along the long
axis of the humerus while the scapula is stabilized
with the other hand
have often failed to be replicated.
Compression Test (Supplementary online Video 14)
228,242
e O’Brien Active
242
is a
widely used test for SLAP lesion. e National Athletic Trainers
Association Position Statement on management of SLAP lesion
in the overhead athlete recommends that the O’Brien Active
Compression Test alone is not diagnostic for a SLAP lesion
based on pooled data.
228
Similarly, support for other tests is
limited by evidence from single studies, including commonly
used tests such as the biceps load I and II, anterior slide,
crank, and compression−rotation tests with likelihood ratios
indicating a moderate or large effect on the post-test probability
of diagnosing a SLAP lesion.
119
However, these commonly used
tests perform far worse when used by individuals other than the
originator of the test.
119
erefore, there is little confidence in a
clinician’s ability to rule in or out a SLAP lesion based solely on
the clinical exam. Also of note, there is overlap in tests used to
diagnose GH joint instability and long head of biceps tendon
injuries with those for SLAP or labral tears, which suggests a
lack of specificity for the painful structure in this anatomical
region.
of findings to rule in a SLAP lesion in the National Athletic
Trainers Association position statement is a history of popping
clicking or catching with a positive anterior slide test (Figure
16). A combination of this test and subjective finding is best
used to rule in, but not out, a SLAP lesion (sensitivity 0.40,
specificity 0.93, +LR 6.0, -LR 0.64).
219
Acromioclavicular joint injuries
While less common than other sources of shoulder
nociception, the AC joint can be a source of pain that may
be overlooked when other shoulder pathologies are ruled in.
Dissimilar to traumatic AC joint injuries, imaging is not helpful
for atraumatic AC joint injuries given the high prevalence of
asymptomatic degenerative changes. Up to 93% of individual
over the age of 30 may demonstrate asymptomatic AC joint
OA with imaging.
244
e location of symptoms is a key factor
used to rule in AC joint pain. Palpation of this joint will clarify
the top of the shoulder and the AC joint itself as a source of
nociception.
245
When one suspects AC joint as a symptom generator, the
combination of pain with palpation and a positive O’Brien active
compression test, with pain located on the top of the shoulder
is used with the ability to rule in the disorder (specificity 97%;
Figure 16.
Anterior Slide Test
Supplementary Online Video 14
https://www.orthoptlearn.org/mod/vimeo/view.php?id=734
Combinations of exam finding typically improve
diagnostic accuracy. A single study suggests the combination
of the passive distraction test and active compression test show
promise (sensitivity 0.70, specificity 0.90, +LR 7.0, -LR 0.11)
to rule in and out SLAP lesions.
243
Another suggested cluster
34
Performed by providing anterior superior force
through the humerus while patient is asked to resist.
A pain or click in the anterior aspect of the shoulder
concordant with the patient’s symptoms is considered
positive for superior labral anterior to posterior
(SLAP) lesion.
Academy of Orthopaedic Physical erapy, APTA.
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sensitivity 7%, +LR 2.08).
https://t.me/med1917
246
When AC joint pain is reproduced
with overpressure in passive horizontal adduction, also termed
cross body adduction test or scarf test, AC joint pathology
should also be considered (specificity 79%, sensitivity 77%,
247
+LR 3.67, -LR 0.29).
proposed to rule in AC joint pain.
Lastly the Paxino’s test has also been
245,246
Paxino’s test is essentially
the testing of AC joint accessory motion performed by placing
the examiners thumb under the posterior lateral aspect of the
acromion and index and middle fingers of the same hand on
the superior aspect of the clavicle. e examiner then applies
pressure in an inferior direction on the clavicle while pushing
the acromion anteriorly and superiorly. Pain and hypermobility
are positive findings. In Type I and II AC joint sprains, pain
provocation tests such as the Paxino, cross body adduction, and
O’Brien’s active compression tests are advocated to confirm the
248
presence of an ACJ injury.
However, these tests have limited
clinical utility in the absence of a relevant traumatic history and
246
relevant signs and symptoms.
CONDITIONS-SPECIFIC EVIDENCE-BASED
REHABILITATION CONCEPTS FOR
NOCICEPTIVE PAIN
Nociceptive, Nociplastic, and Neuropathic
Pain Mechanisms Considerations
Nociceptive, nociplastic, and neuropathic pain may not
respond equally well to traditional shoulder rehabilitation
interventions.
predominant pain presentation should aide to guide initial
treatment choices. Distinct from matched interventions for
patients with predominant nociceptive pain presentations,
interventions most successful in patients with nociplastic
presentation focus on mechanisms to down regulate
sensitization
Patients with high psychosocial risk factors may also benefit
from psychologically-informed rehabilitation approaches and
for some, a referral for inter-disciplinary care with evaluation for
pharmacological intervention or psychotherapy may be needed.
ere can be considerable overlap in pain presentations.
Some patients with nociceptive shoulder pain may also present
with neuropathic findings as indicated with the PainDETECT
profile
a scenario, interventions that address neuropathic symptoms
(eg, interventions directed to the spine and/or neurodynamic
mobilizations) and nociceptive shoulder pain are both indicated.
In patients identified to have a nociplastic pain presentation,
a nociceptive source may also be identified. Interventions for
nociceptive sources of pain classified with the STAR-Shoulder
discussed below should then be supplemented by pain
education, graded exposure, and other psychologically-informed
rehabilitation approaches. Additionally, aerobic activity and
isometric exercise may reduce central excitability and enhance
descending pain inhibition as evidence-based interventions used
to target nociplastic pain mechanisms.
110
e clinician’s understanding of the
249
and upregulate descending pain inhibition.
169
and positive upper limb neurodynamic tests. In such
251
Regardless of the pain
250
presentation, patients with high psychological risk profiles (eg,
pain catastrophizing, fear of movement, anxiety, and depression)
have compromised outcomes with traditional rehabilitation.
us, other psychologically-informed interventions including
pain education should be used.
Level Three: Rehabilitation Classication
and Matched Interventions
Using the STAR-Shoulder as the underlying diagnostic
framework, clinical practice guidelines for the primary shoulder
132
disorders have been published
or are under development.
ese guidelines integrate the World Health Organization
International Classification of Functioning, Disability and
Health (ICF). e body function and structure, activity
limitations, and participation restrictions, described using ICF
terminology, (1) categorizes patients into mutually exclusive
impairment patterns upon which to base intervention strategies,
and (2) serve as measures of change in function over the course
132
of an episode of care.
ese guidelines link pathoanatomic
diagnoses with the primary associated impairment in body
structure and function. As such, the diagnosis of adhesive
capsulitis is linked to ICF language of Shoulder Pain and
132
Mobility Deficits,
subacromial pain syndrome is linked
to ICF language of Shoulder Pain and Muscle Performance
Deficits, and shoulder instability is linked to Shoulder Pain and
Motor Coordination Deficits.
With each pathoanatomic diagnosis, the rehabilitation
classification of the STAR-Shoulder identifies the patient’s
individual impairments associated with the movement problem
130
and the irritability stage.
As the patient progresses from
high to low irritability, additional assessment of impairments
contributing to movement dysfunction and the aggressiveness of
interventions used to target these primary impairments can be
accordingly adapted. Appropriately matching the intervention
to the irritability level is rather intuitive for experienced clinicians
but requires some guidance with novice clinicians and students.
Examples of interventions used to target common impairments
in patients with shoulder pain are shown in Table 6.
Patient education
Regardless of the patient’s shoulder condition, patient
education is paramount to successful intervention and patient
outcomes. Patient education should take into account the
patient’s beliefs of the problem, expectations for recovery, and
preferences for interventions. e patient should also be educated
on other aspects of managing pain, including remaining active
and addressing fear avoidance behavior with focus on gradual
return to usual activities and/or modifying rather than avoiding
activities. A comprehensive approach to well-being should at
minimum include education in managing mental health and
referral for care when appropriate, the importance of sleep
with advising in sleeping positions to reduce pain at night,
implication of nutrition, smoking, general health, and the
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35
Table 6.
https://t.me/med1917
Matched Interventions Based on Classification of Impairments and Irritability Level for Individuals
with Shoulder Pain*
Impairment High Irritability Moderate Irritability Low Irritability
Nociplastic pain and
functional activity
intolerance
Pain education
Active rest
Graded exposure
Psychologically-informed rehabilitation
Isometric and aerobic exercise to enhance descending inhibition
Referral for adjunctive care
Nociceptive pain and
functional activity
intolerance
Activity modification
-unloading focus
Physiological ROM in midranges
Manual therapy
Electrophysical agents
Aerobic activity
Neuropathic pain Low-grade neural
mobilization, physiologic
ROM, mid-range
Limited passive mobility:
joint/muscle/neural tissues
ROM in pain-free ranges,
manual therapy: typically
not to end-range
Excessive passive mobility Protect joint/tissue from
end-range ROM
Limited immobilization
Isometrics of surrounding
musculature
Neuromuscular weakness
associated with disuse,
Active ROM within painfree ranges
atrophy, and deconditioning
Activity modification
-progressive loading focus
Manual therapy
Limited electrophysical
agents use
Aerobic activity
High-grade neural
mobilizations, intermittent
end-range ROM and
stretching
ROM, stretching, manual
therapy: comfortable
end-range, typically
intermittent
Develop active muscular/
joint control in mid-range;
avoid end-ROM
Treat hypomobility of
adjacent joints or tissues
Progressive resisted
exercise, light to moderate
loading mid-ROM
Activity re-integration –
progressive high-loading focus
No electrophysical agents
Aerobic activity
High-grade neural
mobilizations, end-range ROM
and stretching, longer duration
and frequency
ROM, stretching, manual
therapy: end-range, high-grade,
longer duration and frequency
Develop active muscular/joint
control in full ROM
High-level functional activity
Address hypomobility of
adjacent joints or tissues
Moderate or high resistance to
fatigue
Neuromuscular control/
weakness/muscle activation
Abbreviations: NMES, neuromuscular electrical stimulation; ROM, range of motion
*Modified from McClure and Michener
benefits of exercises. Details regarding the appropriate levels of
pain during and after exercise, and how long to continue with a
home program are necessary components of patient education.
Making use of available educational resources explaining
pain physiology is advocated.
provided with a pathoanatomical diagnosis for shoulder pain
without a potential understanding that many pathologies
are often asymptomatic,
Active ROM within painfree ranges
Consider biofeedback,
NMES, or other neural
activation strategy
130
252
Too often patients have been
253
not consistently associated with
Neuromuscular control
training with ROM and
focus on quality and
High-demand neuromuscular
control training with focus on
quality rather than resistance
precision rather than
loading according to
motor learning principles
254
symptoms,
not change as patients pain and function improve.
not predictive of treatment outcome,
255
psychological factors such as patient expectations of recovery
have a great effect on treatment outcomes.
114,186,256
the language used to communicate about the patient’s shoulder
condition (pain) should not focus on the pathoanatomy due to
the potential to negatively impact anxiety and stress.
there is a consistent association between a patient’s expectation
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36
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For personal use only. No other uses without permission.
114
and do
In contrast,
erefore,
257
Because
of treatment outcome and actual outcome, patient education
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should include describing the typical trajectory and prognosis
of recovery with physical therapy intervention.
While exercise is the cornerstone of physical therapy
management and successful patient outcomes, evidence
suggests that patients’ adherence to exercise prescribed by
physical therapists is poor.
258
Strategies to increase adherence
are paramount to achieving good outcome with physical
therapy interventions. Perceived simplicity and short duration
of treatment, immediacy of benefit, and absence of side effects
260
259
to
are known factors that increase patient adherence to exercise.
Behavioral techniques can be used to address barriers
exercise. Examples include the creation of action plans with the
patient for where and when exercises will be done, contingency
plans, creating text or messaging prompts, discussing how
to modify exercise if pain increases, and using exercise
adherence diaries.
261
Additionally the therapist can provide
reassurance about the condition and capacity to exercise and
prescribe a manageable amount of exercises (limited to 2 or
3) to be performed at home.
261,262
Lastly, the therapist should
establish goals in agreement with the patient that is linked to
achievement with the exercise plan. Interventions that include
behavioral techniques to maximize exercise adherence are skills
that physical therapists can learn that may improve patientrated outcomes across a variety of shoulder specific conditions.
Adhesive capsulitis: mobility deficit
Specific examination findings used to confirm adhesive
capsulitis include a global and progressive loss of both active
and passive ROM and increased pain with end-ranges of
motion.
130,263
e ICF category for this diagnostic group is
Shoulder Pain and Mobility Deficit, because limited motion
is the consistent movement related impairment characterizing
this subgroup. e hallmarks of primary adhesive capsulitis
are the spontaneous loss of shoulder motion and specifically
limitations in shoulder ER ROM. Primary adhesive capsulitis is
more common in women, between 40 and 65 years of age, and
in those with diabetes, hypothyroidism, or other autoimmune
diseases.
132
Other red flag pathologies that may mimic primary
adhesive capsulitis include joint associated infections, septic
arthritis, malignancy, and inflammatory arthropathy including
polymyalgia rheumatica. As such, patients who present with
primary adhesive capsulitis should be referred for radiographs
to rule out sinister pathology or differentiate from an early onset
of GH joint OA. In contrast to primary adhesive capsulitis,
secondary adhesive capsulitis is typically a result of a period of
immobilization.
Symptoms of pain and stiffness with primary adhesive
capsulitis has been theorized to progress through a 4 stage
continuum from mild symptoms (pre-freezing) to freezing,
frozen, and ultimately the thawing stage that on average occurs
approximately 18 months after the appearance of the initial
symptoms.
132,264,265
e interventions selected for adhesive
capsulitis are based on the stage of the process characterized by
the level of pain and irritability, the chronicity of the condition,
and disability experienced by the patient.
130,266,267
Patients often complain of high levels of pain severity,
irritability of the condition, and loss of motion (impairment)
which impact their ability to perform activities of daily living
(ADLs) and other functional activities. is information helps
guide the selection of therapeutic interventions and the intensity
level of the treatment to optimize the patient’s recovery.
130,132
To establish a comprehensive care plan for the patient with
adhesive capsulitis it is important to determine the behavior
and intensity of pain, the magnitude of shoulder motion loss
and associated end-feels, the current functional restrictions, and
the patient’s daily demands and goals.
130,132
Physical therapy aimed at the restoration of movement and
reduction of pain has been a focus of non-operative management
of adhesive capsulitis. Physical therapy may be prescribed as
an isolated treatment or is often suggested in combination
with other interventions. e patient’s presentation should be
classified based on the results of the evaluation in accordance with
the previously published stages of irritability (high, moderate,
or low).
130,132
e classification system has been designed
to assist the clinician to match interventions for pain and
stiffness to progress through the 4 stage continuum from mild
symptoms to freezing and ultimately the thawing stage.
132,264,265
Continuous evaluation of the patient is necessary to revise the
treatment classification and to adapt the interventions based on
the patient’s progress and needs.
Interventions used to improve ROM and function, and
decrease pain in patients with adhesive capsulitis include
education and activity modification, medications (oral and
injections), joint mobilizations, electrophysical agents, and
exercise therapy focused on ROM.
132
e available evidence
strongly supports the use of intra-articular steroid injections in
combination with mobility and stretching exercises.
132
is is
particularly encouraged in patients with high tissue irritability
as indicated by high pain severity and disability, pain limiting
passive joint mobility, and difficulty sleeping, which are
characteristic of the early stages. Moderate evidence supports the
use of patient education to guide their home exercise program
and modification of their activities.
132
Prolonged stretching
exercises within patient tolerance are supported at a moderate
level to treat patients with adhesive capsulitis.
132
Specific details of which exercise or manual therapy are
best for patients with primary adhesive capsulitis is lacking.
One randomized trial found that high-grade mobilization with
terminal passive stretching is less effective in improving pain and
function than education and a home exercise program for ROM
within pain limits.
268
is supports the matched irritability
concept proposed by the STAR-Shoulder. Additionally, a
single randomized trial found that posteriorly directed GH
joint mobilizations are more effective than anteriorly directed
mobilizations to improve shoulder ER ROM. Supplementary
online Videos 15-18 provide selected examples of accessory
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For personal use only. No other uses without permission.
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37
motion testing and mobilization techniques for the GH joint.
https://t.me/med1917
While the majority of patients regain mobility and function over
the course of a year, some patients present with residual ROM
and functional deficits that may require treatment beyond 18
months.
132
Supplementary Online Video 15
https://www.orthoptlearn.org/mod/vimeo/view.php?id=735
Supplementary Online Video 16
https://www.orthoptlearn.org/mod/vimeo/view.php?id=736
Supplementary Online Video 17
https://www.orthoptlearn.org/mod/vimeo/view.php?id=737
Supplementary Online Video 18
https://www.orthoptlearn.org/mod/vimeo/view.php?id=738
Interventions to address the presence of fear avoidance
behavior and psychosocial factors that may contribute to
the patient presentation of early stages of primary adhesive
capsulitis
269
are a special consideration in this patient population.
Fear avoidance and other psychosocial factors that may impact
outcomes can be identified with the yellow flag assessment
during the screening process. Readers are referred to a published
case report that illustrates the integration of a cognitive based
approach to rehabilitation for a patient with adhesive capsulitis
that includes a positive outlook on recovery, lifestyle behavior
change (sleep, nutrition, stress reduction, moderate intensity
aerobic activity), graded motor imagery, and mirror therapy.
269
Post-operative primary adhesive capsulitis
Surgical treatments are often recommended in patients
who have protracted symptoms (3-6 months) with little relief
regardless of treatment.
267,270
Types of operative treatment
offered include manipulation under anesthesia, brisement
(hydrodilitation), and arthroscopic capsular release. ese
treatments focus on increasing capsular volume by releasing
scarring through mechanical manipulation, injection of fluid,
or resection of the scar. e post-operative course begins with
minimal sling use and frequent arm motion and activity.
270
Rehabilitation focuses on gaining full ROM as soon as possible
with consistent and frequent home stretching.
267,270
Subacromial pain syndrome: muscle performance deficit
Subacromial pain syndrome (or associated synonyms such
as subacromial impingement, rotator cuff-related shoulder
pain, rotator cuff tendinopathy, or rotator cuff disease) is
the most common musculoskeletal shoulder disorder seen in
primary care.
271
e ICF category for this diagnostic group
is Shoulder Pain and Muscle Performance Deficit, as the
consistent movement related impairment. Examination of
patients with subacromial pain syndrome reveals pain in the
deltoid region associated with a history of relative shoulder
272
overuse.
As previously discussed, the cluster of findings
that are recommended to rule in subacromial pain syndrome
include a painful arc, positive impingement signs (Hawkins,
Neer, and Jobe/Resisted Empty Can), and pain or weakness
130
with resisted shoulder ER.
ere may be involvement of the
long head of the biceps tendon and potentially positive findings
for a SLAP lesion. However, there are no examination findings
of apprehension with instability tests, subjective complaints
of an unstable, loose, or subluxating shoulder, or significant
loss of motion, which would make the clinician consider
130
other diagnoses.
e validity for identifying pathoanatomic
diagnosis, such as bursitis, rotator cuff tendinopathy, or partial
118,121
thickness rotator cuff tear has been challenged.
term subacromial impingement is discouraged
Use of the
127
as qualitative
studies highlight the patient’s concerns with use of terms that
infer a structural problem (eg, hooked acromion) that cannot
186,218,257
be altered with physical therapy interventions.
us the
therapist should be cognizant of terms used with the patient
that may negatively impact the patient outcome.
Assessment and prioritization of individual movement
impairments include muscle performance of the rotator cuff
and scapular primary movers, posterior shoulder tightness
273
or GIRD, shortened pectoralis minor length,
274
tissue stiffness in the infraspinatus,
163
mobility,
kinetic chain deficits,
thoracic spine position/
275
and pain sensitivity
altered soft
276
with
reduced pressure pain thresholds. Central changes related to the
chronicity of symptoms has also been shown in patients with
subacromial pain syndrome.
277
Based on randomized trials and systematic reviews,
exercise is recommended as the first choice of intervention for
225
subacromial pain syndrome with comparable outcomes,
at a lower cost and with fewer risks, than surgery.
67
Exercise
but
is more effective in reducing pain and function than no
treatment although the optimal type, dose, and load of exercise
225
intervention is unclear.
ere is some evidence that home-
directed programs are effective in improving patient-reported
278
outcomes.
Whether symptoms should be aggravated during
or after exercises is debated, but mild to moderate pain with
gradual progressive resistance exercises targeting the rotator
272,279
Duration of exercise programs should be based on individual
cuff and scapular muscle force couples may be expected.
patient contributing impairments and personal and
environmental factors. Clinically meaningful improvements are
expected within 12 weeks.
Exercises to strengthen the posterior rotator cuff and load
the shoulder into an elevated position are essential components
of an evidence-based program. Examples of corresponding
interventions commonly used to resolve impairments as
categorized by irritability level are identified in Table 7. Typically,
interventions to modulate pain for patients who are categorized
in the high irritability category include activity modifications,
38
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