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Table 11.
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Patient-Reported Outcome Measures Used in Patients with Shoulder Disorders
Name Scale Range & Direction Subscales
Patient Specific
Functional Scale
414,430-433
(PSFS)
Single Assessment
Numeric Evaluation
(SANE)
434,435
Disabilities of the Arm,
Shoulder, & Hand
(DASH)
436-441
Quick Disabilities of the
Arm, Shoulder, & Hand
(qDASH)
437,442-444
Penn Shoulder Scale
407
(PSS)
Shoulder Pain &
Disability Index
(SPADI)
438,439,445-447
Association of Shoulder
& Elbow Surgeons
435,438,447,448
(ASES)
Constant-Murley Score
(Constant)
435,436,439,449,450
0 (0%) = Worst function;
10 (100%) = Best function
0 (0%) = Worst pain & function;
10 (100%) = Best pain &
function
0 (0%) = Absence of disability;
100 (100%) = Total disability
0 (0%) = Absence of Disability;
100 (100%) = Total Disability
0 (0%) = Worst pain, satisfaction,
& function; 100 (100%) = Best
pain, satisfaction, & function
0 (0%) = Absence of pain &
disability;
100 (100%) = Total pain &
disability
0 (0%) = Worst pain & function;
100 (100%) = Best pain &
function
0 (0%) = Total pain & disability,
worst objective measures;
100 (100%) = Absence of pain
& disability, normal objective
measures
Not applicable 0.4–1.5 1.0–2.5 0.8–3.0
Not applicable 2.9–5.2 6.7–8.6
Not applicable 2.8–7.6 6.6–16.1 8.2–11.7 0.6–2.2
Not applicable 3.3–10.2
Pain (0 – 30)
Function (0 – 60)
Pain (0 – 50)
Disability (0 – 50)
Pain (0 – 50)
ADL (0 – 50)
Pain (0 – 15)
ADL (0 – 20)
ROM (0 – 40)
Strength (0 – 25)
Measurement Properties
SEM MDC MCID SRM
11.8–
18.0
11.0–
20.4
8.0–15.9 0.6
8.5 12.1 11.4 1.3Satisfaction (0 – 10)
6.2–7.8
18.0–
18.1
10.0 1.0–1.7
6.7 9.4 6.4–21.9 0.9–2.2
6.5 17.7 5.5–30.0 0.6–2.4
0.8
Physical symptoms
Western Ontario
Shoulder
Instability Index
(WOSI)
410,451-453
0 = Absence of disability;
2100 = Total disability
0% = Total disability;
100% = Normal function
(0 – 1000)
Sports/recreation/
work (0 – 400)
Lifestyle (0 – 400)
122.4 339.3
210.0–
220.0
0.9–1.7
Emotions (0 – 300)
Physical symptoms
(0 – 600)
Western Ontario
Rotator Cuff Index
(WORC)
411,447,454
0 = Absence of disability;
2100 = Total disability
0% = Total disability;
100% = Normal function
Sports/Recreation
(0 – 400)
Work (0 – 400)
Lifestyle (0 – 400)
6.9
of 100
19.1
of 100
245.3–
300.0
0.9
Emotions (0 – 300)
Physical symptoms
Western Ontario
Osteoarthritis
Index of the Shoulder
(WOOS)
412,435
0 = Absence of disability;
1900 = Total disability
0% = Total disability;
100% = Normal function
(0 – 600)
Sports/recreation/
work (0 – 500)
Lifestyle (0 – 500)
… … … 1.9–2.4
Emotions (0 – 300)
Abbreviations: ADL, activities of daily living; MCID, minimal clinically important difference; MDC, minimal detectable change; ROM, range of motion;
SEM, standard error of the measure.
Note: Statistical properties listed represent a sample of values available for each patient-reported outcome measure. It is important to perform periodical
literature reviews for updates and patient population-specific values if not reflected above.
Academy of Orthopaedic Physical erapy, APTA.
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49
questionnaire and the DASH allowing for a deeper dive into
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specific functional activities.
Shoulder specific outcome tools describe general shoulder
function or disability related to common functional demands
407-409
or activities.
Shoulder specific tools commonly used in the
United States include the ASES Score, the Penn Shoulder Score
(PSS), and the Shoulder Pain and Disability Index (SPADI).
e ASES consists of 10 multiple choice questions related to
a patient’s level of difficulty completing activities that account
for half of the total score, and a numeric pain rating (on a
0-10 scale) is weighted to account for the remaining 50% of
the scale. erefore, the ASES score is highly influenced by a
single pain question. e PSS combines 24 multiple choice
questions related to a patient’s level of difficulty completing
activities (60%) with 1 question related to patient satisfaction
(10%), and 3 questions related to pain (30%). Embedded in the
PSS are questions used to establish an ASES score (10 Likertscale difficulty with activity questions and pain with activity
measure). e SPADI consists of 5 questions related to pain and
8 questions related to disability with each subsection weighted
evenly for the total score. While often used for all patients with
upper extremity or shoulder conditions, these PROMs are
not tailored to specific patient populations and may lack the
sensitivity needed to discern functional ability for impairments
related to pathology-specific shoulder conditions.
Condition-Specic Outcome Tools
Several pathology/condition-specific PROMs exist that
address functional impairments commonly associated with
instability, rotator cuff pathology, and OA. e WOSI is made
up of 21 questions that use a visual analog scale (VAS) ranging
from 0-100 across 4 subsections (physical symptoms, sports/
410
recreation/work, lifestyle, and emotions).
Each question is
weighted evenly allowing for a total score out of 2100 points—
commonly reported as a percentage. e Western Ontario
Rotator Cuff Index (WORC) is also made up of 21 questions
that use a 100-point VAS—but is split into 5 subsections
(physical symptoms, sports/recreation, work, lifestyle, and
411
emotion).
e Western Ontario Osteoarthritis Index of the
Shoulder (WOOS) is made up of 19 questions, also using the
100-point VAS, and is made up of 4 subsections (physical
symptoms, sports/recreation/work, lifestyle, and emotions).
412
Subjective complaints of patients for shoulder instability,
rotator cuff pathology, and OA differ significantly—and these
PROMs provide the specificity and sensitivity needed to assess
function and identify functional progress for these complaints.
ree final PROMs offer differing approaches to
understanding patient function. Among them, the ConstantMurley score blends subjective patient responses related to pain
(15%) and ADLs (20%) with objective tests including ROM
413
(40%) and strength (25%).
While commonly used in Europe,
it is not widely administered in the United States.
Other Patient-Reported Outcome Measures
e Patient Specific Functional Scale (PSFS) asks the
patient to identify and rate their ability to perform 3-5 functional
activities important to them that their musculoskeletal condition
414
limits.
e PSFS is beneficial because it allows the therapist
and patient to track their ability to perform the activities most
important to them—and likely that drove them to seek care
in the first place. e Single Assessment Numeric Evaluation
(SANE) is a 1-item survey that simply asks the patient “How
would you rate your shoulder today as a percentage of normal
(0% to 100% scale with 100% being normal)?”
415
Initially
introduced to assess shoulder function, modified versions have
demonstrated validity for conditions related to the shoulder,
knee, neck, back, hip, and ankle.
416
e SANE is beneficial
because it allows the patient to provide a single rating relative to
their “normal,” considering pain, functional ability or disability,
and satisfaction. It is easy to administer and provides an efficient
means to routinely track progress.
Measurement Properties
After consideration of an outcome’s utility, it is important
to have a general understanding of the statistical properties of
the measure. Validity is a measure of the extent that a PROMs
does what it is intended to measure. Four commonly described
types of validity are face, content, construct, and criterion
validity. Understanding the utility of an outcome measure in
relation to your patient’s functional status and goals serves as an
initial check for the PROM’s validity.
After determining the validity of a PROM for a patient or
group of patients, it is important to understand the reliability
(ie, precision reflective of measurement errors related to
repeated measurements) of the measure. Reliability statistics
commonly reported include intraclass correlation coefficient
(ICC), standard error of the measure (SEM), and MDC. ese
measures identify the reproducibility of a measure (ICC) and
threshold for a statistically important difference when scores
clinically important difference (MCID) and substantial clinical
benefit (SCB) establish the quantity of change needed on the
PROM for the difference to be minimally or substantially
clinically important at a patient level. Responsiveness of a
PROM is a similar measure that establishes the ability of a
measure to detect change over time when changes actually occur.
Commonly reported as a standardized response mean (SRM),
responsiveness compares the magnitude of change against the
standard deviation of the PROM. Finally, scale attenuation
effects (for example, floor and ceiling effects) are especially
important to consider when managing patients with very high
or low functional status or goals. Ceiling effects measure the
percentage of patients that score the highest possible value (for
example, absence of pain, maximal function); while floor effects
measure the percentage of patients that score the lowest possible
value (for example, maximal pain and disability). ere are no
50
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uniformly accepted values for floor and ceiling effects; however,
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understanding the relationship between the floor and ceiling
effects and functional status and goals of the patient is vital (for
example, for a patient with high functional demand, near-zero
ceiling effects are desired).
Functional Testing and Return to Participation
It is important to consider PROMs in the context of the
entire clinical picture. History intake, pain, irritability, and
ROM and strength assessments provide valuable information
regarding patient status. Additionally, it is vital to objectively
test and monitor progress of functional tasks related to patient
goals. Examples of validated upper extremity functional tests
include the Y Balance Test – Upper Quarter (YBT-UQ)
and Closed Kinetic Chain Upper Extremity Stability Test
(CKCUEST) for stability, the Seated Medicine Ball row
(SMBT) for power, Shoulder Arm Return-to-Sports (SARTS)
battery for comprehensive upper extremity testing, Posterior
Shoulder Endurance Test (PSET) for shoulder conditioning and
stability, Timed Functional Arm and Shoulder Test (TFAST) for
417-423
lower level upper extremity functional demands.
Further,
physical therapists—as human movement experts—should
partner with their athletes (in fact all patients) to develop any
additional required functional testing that adequately monitors
progress toward their goal of returning to sports/work/activity
participation.
After completion of the initial 3 phases of rehabilitation—
where the patient’s ROM, strength, PROMs, pain, and
functional testing have progressed to a pre-determined threshold
(for example, at or within 5% of “normal” for all measures
described)—a physical therapist should take the patient through
a rigorous return-to-high demand activity testing protocols,
including return to sport or high demand occupations. Previous
work has highlighted key considerations that should inform the
424
return to sport testing process.
ese include pathology, injury
mechanism, previous injury, treatment type, tissue healing
potential, and time-loss from participation. While outside the
scope of this monograph, sufficient resources on this topic are
available in peer-reviewed literature and through the Academies
of Orthopaedic Physical erapy and Sports Physical erapy.
Risk-Adjustment Using Patient-Reported
Outcome Measures
With for quality-based reimbursement, it is important
to consider risk-adjustment that controls for baseline patient
presentation. ere is no peer-reviewed literature in the
physical therapy space regarding risk-adjustment of shoulder
outcomes described above; however, risk-adjustment of the
most commonly used PROMs for non-operative patients with
back and neck conditions has been established, and a white
paper has described the initial process for risk-adjustment using
425-427
the qDASH for shoulder conditions.
428
established the risk-adjustment process to compare surgeon
al
Further, igpen et
performance using the ASES. As reimbursement is increasingly
tied to the quality and value of healthcare services rendered,
greater understanding of risk-adjustment in the physical therapy
space is warranted.
Summary and Implications for Practice
e selection of PROMs should be intentional and reflect
the patient’s goals and functional capacity. For patients who
require a high-level of function, it is important to consider a
PROM that targets specific functional or condition-specific
deficits and has near-zero ceiling effects. Clinicians should have
a good understanding of the PROM and why they are used.
ey should assist in guiding and progressing care. Achievement
of a MCID is emphasized; however, should not be the ultimate
gauge of success with patients. e MCID represents the
minimal amount of change that is likely perceptible to a patient;
however, there is variability in how it is calculated and questions
429
remain on its relative importance at a patient level.
Riskadjustment offers another approach to assess the importance of
change; however, it is not yet widely used with physical therapy
PROMs. erefore, it is important to partner with patients to
establish functional goals; monitor progress with a blend of
objective clinical measures, PROMs, and validated functional
tests; and use appropriate return to participation or sport testing
to guide patients in criterion-based decisions.
CONCLUSION
Physical therapists have typically considered the underlying
pathology and pathoanatomy in the examination and evaluation
of the patient. Contemporary rehabilitation includes best
evidence to categorization of patients into diagnostic categories
and use of the ICF classification of the primary impairment
in body structure and function. Examination of the patient is
less focused on results of the many special tests and maneuvers
proposed by experts but focused on clusters of examination
findings and the use of reliable and valid tests and measures.
Understanding the many situations when the patient care
pathway may necessitate a referral to other providers is essential.
ese may include identifying when a rotator cuff tear is a
red flag, the presence of high psychosocial risk factors found
to negatively impact prognosis, or when concomitant intraarticular injection may be a helpful adjunct to physical therapy
intervention. Using symptom modification examination
findings and determining the predominant pain mechanism(s)
are essential to guide relevant physical therapy intervention
choices. e use of pain severity and irritability of the condition
to select appropriate examination procedures and evidencebased interventions are useful for novice clinicians and students.
Integrating clinical practice guidelines and contemporary
evidence to guide examination and intervention choices is
necessary to enhance patient outcomes and reduce unwarranted
variation in practice.
Academy of Orthopaedic Physical erapy, APTA.
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© 2021 Academy of Orthopaedic Physical erapy, APTA, Inc. All rights reserved.
51
CASE SCENARIOS
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Case Scenario 1
History and interview
e patient was a 62-year-old right hand dominant male
referred to physical therapy secondary to complaints of right
shoulder pain and reduced shoulder mobility (Penn Score
53/100). e patient reports an approximate 18-month history
of pain, however, presently his pain had progressively worsened
with increased symptoms at night (numeric pain rating 8/10)
and after activity (numeric pain rating 6/10). e patient noted
decreased strength and capacity for activity and a significant
increase in pain and limitations at work and with recreational
activities. He denied any cervical pain or problems with
sensation.
e patient worked for a large manufacturing company.
His primary job responsibilities included climbing ladders,
working overhead consistently, and lifting equipment. His
hobbies included hunting by bow and rifle. e patient was
seeking physical therapy for his shoulder pain through direct
access. His sister recommended this based on her successful
outcome with physical therapy intervention for her shoulder
pain. He lives at home with his wife, who was under the care of
hospice for metastatic lung cancer.
Systems review
He denies any alcohol or drug use beyond prescription
medicine (Voltaren) but smokes one pack per day. Past medical
history includes Stage 1 soft tissue sarcoma in his right leg
that was successfully resected 5 years ago. He subsequently
underwent radiation therapy. Systems review for yellow and
red flag signs and symptoms was conducted and deemed
appropriate to proceed with the examination. Patient denies
recent unexplained weight loss, night sweats, loss of appetite,
or extreme fatigue.
Tests and measures
Upon observation, the patient was avoiding shoulder
internal rotation (IR) behind the back movement while taking
off his jacket and shirt. He had mild scapular asymmetry
with a downwardly rotated and protracted right shoulder.
Static cutaneous sensation was normal in all upper extremity
dermatomes. Deep tendon reflexes appear bilaterally
symmetrical and normal. His cervical spine range of motion
was minimally restricted in all planes of motion and pain free.
Active shoulder forward elevation was painful and limited to
142° on the right and 164° on the left. External rotation (ER)
at 0° abduction was measured at 15° on the right versus 52° on
the left. Combined IR up the back was to the gluteal fold on
the right versus T12 on the left. All shoulder ROM was painful
on the right with some scapular substitution noted but not on
the left. Passive ROM of the right glenohumeral (GH) joint was
limited in all planes, ER to 5°, abduction to 80°, IR at 45° of
abduction to 20°, all with painful firm end-feels. Crepitus was
noted with passive joint mobility testing on the right. Strength
testing for shoulder ER/IR at the side was not tolerated on the
right secondary to pain, but was 28 and 36 pounds on the left,
respectively, using a hand-held dynamometer.
1.
Based on the history and objective information, what is the
most likely pathoanatomic diagnosis for this patient?
a. Primary adhesive capsulitis.
b. Primary glenohumeral joint osteoarthritis (OA).
c. Rotator cuff arthropathy.
d. Subacromial pain syndrome.
e correct answer is b. Primary glenohumeral joint
osteoarthritis (OA). As outlined in Shoulder Osteoarthritis,
characteristics of shoulder OA include increasing limitations
in ROM, stiffness, and pain with compression of the joint in
older adults. As reported in Adhesive Capsulitis: mobility decit
the symptoms the patient experiences are similar to that of
adhesive capsulitis, including ROM deficits and stiffness.
However, timeline with current presentation of high irritability
is not consistent with primary adhesive capsulitis. Degenerative
rotator cuff tears can cause secondary glenohumeral OA, termed
rotator cuff arthropathy, as highlighted in Rotator Cu Tears.
However, the patient was able to actively elevate to 142° which
is less likely in patients with rotator cuff arthropathy. With
subacromial pain syndrome, the patient would most likely be
able to externally rotate beyond the reported 15° as the tendon
would be intact.
2. Based on the hypothesized diagnosis and patient history,
what is the most appropriate care pathway at this point?
a. Continue with treatment, refer for imaging after 6 weeks
of physical therapy if symptoms persist and function is
unchanged.
b. Refer for imaging and initiate pain-free ROM exercises.
c. Discuss and outline non-surgical pain management
strategies.
Supervised neglect with watchful waiting over the next
d.
6 months.
e correct answer is b. Refer for imaging and initiate
pain-free ROM exercises. Due to the patient’s history of cancer
and provisional diagnosis of GH joint OA, the most appropriate
course of action would be to refer the patient for imaging as
discussed in GH Osteoarthritis section of the monograph.
Continuing with any other intervention without referral is not
indicated given risk of metastasis associated with prior history
of cancer.
Diagnosis
e patient returned to the clinic after follow-up with his
primary care physician. Magnetic resonance imaging taken of
the right shoulder showed mild narrowing of the GH joint
52
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space with osteophyte formation along the humeral head.
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e acromioclavicular joint space was narrowed with mild
osteophyte formation. e acromiohumeral distance was
preserved. No soft tissue lesions were identified. Based on the
imaging findings, GH joint OA is confirmed and concern of
metastatic cancer was abated. e patient was referred to a
shoulder surgeon who recommended surgery, but the patient
prefers non-surgical interventions given his history of cancer a
few years ago and having to care for his wife who is in hospice
now.
3.
What is your recommendation at this time for his plan of
care?
a. Proceed with surgery with total shoulder arthroplasty.
b. Proceed with trial physical therapy with interventions
matched to pain severity and irritability levels and reevaluate progress.
c. Proceed with trial physical therapy intervention with
high-grade mobilization, continuous passive motion
(CPM), terminal stretching exercise.
Proceed with the use of transcutaneous electrical nerve
d.
stimulation (TENS) and rest.
e correct answer is b. Proceed with trial physical
therapy with interventions matched to pain severity and
irritability levels and re-evaluate progress. e patient
demonstrates mild to moderate arthritic changes to the GH joint
and has preferences for non-operative treatment. Interventions
matched to patient irritability should not exacerbate the
patient’s symptoms. As discussed in Glenohumeral Osteoarthritis
in the monograph, evidence shows improvement in both pain
and function in patients with GH joint OA treated with formal
physical therapy at 2-year follow-up. A trial of physical therapy
intervention to address GH joint pain and mobility deficits with
interventions appropriately matched to irritability condition is
warranted. End-range terminal stretching, CPM, and highgrade joint mobilizations are not appropriate given irritability
levels and risk exacerbating the patient’s symptoms. While the
patient’s overall prognosis for resolution of the shoulder pain is
limited secondary to the length of time that he has been having
symptoms, the patient’s expressed desire for self-care and nonoperative intervention warrants this course of action.
Prognosis and plan of care
e care plan included providing educational selfmanagement tools, such as Centers for Disease Control and
Prevention arthritis handbook to assist the client in identifying
community resources and other strategies to increase function
while decreasing joint stress. A therapeutic exercise program and
manual therapy to promote joint mobility within the patient’s
tolerance, matched to the pain severity and irritability levels, was
critical to assist the patient’s understanding of safe progression
of activity. e patient requested a plan that included therapy
1 time per week for 6 weeks to accommodate his time at home
with his wife.
4. Based on the examination data presented earlier, what is
the best matched rehabilitation intervention at this time?
a. Low grade physiological ROM with joint distraction
within pain tolerance, pendulum exercises, ER ROM
with elastic band, GH joint distraction, and table slides
to prayer stretch.
b.
End-range terminal stretching with prolonged duration
in horizontal adduction, IR and ER isotonic exercises in
side lying, IR stretch up the back with towel or pulleys.
c. Closed chain stability exercises in plank position,
mid-range strengthening in extension, and rhythmic
stabilization at end-range shoulder elevation.
d. Medications and immobilization in a sling for 1 week.
e correct answer is a. Low grade physiological ROM
with joint distraction within pain tolerance, pendulum
exercises, ER ROM with elastic band, GH joint distraction,
and table slides to prayer stretch. e patient presents with
high irritability based on Penn Shoulder Score and pain severity,
and end-feels are painful. e patient’s primary impairment is
pain and limited GH joint passive ROM. e best matched
interventions are those targeted towards pain and mobility
with high irritability as illustrated in Table 6. End-range
terminal stretching with long duration holds and stretching
into combined motions with IR behind the back with a towel
are reserved for patients with low irritability levels. While
strengthening in mid-range may be tolerated, high resistive
loads in plank positions and in extension are likely to exacerbate
symptoms and do not target the primary impairment of GH
joint mobility deficits.
Outcome
e patient was discharged following 6 physical therapy
visits with a Penn Score of 78. e patient was seen less frequently
to allow for care of his wife at home and independent progression
with home exercises given chronicity of the condition. Progress
was made in 6 weeks with active ROM improved to 150° of
forward elevation and 20° of ER. Behind the back IR was to L5
with pain 3/10 at end-ranges. He demonstrated increased ability
to perform activities at home and at work and was content
continuing with his home program and formal discharge from
physical therapy. He had plans to follow up with his surgeon
next year and reconsider surgery at that time.
Case Scenario 2
History and interview
An 18-year-old female competitive swimmer was referred
for physical therapy with complaints of bilateral anterior
shoulder pain that began gradually with swimming 2 months
ago, mid-season. Her pain increased and performance decreased
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53
during the second half of the season. Her pain level escalated
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throughout practice and regularly interfered with her ability to
sleep. She rated her pain immediately following practice as an
8/10 on the right and 7/10 on the left. She did not notice any
limitations in her shoulder range of motion (ROM) and could
perform all her swimming strokes but was concerned about
upcoming national competition. She reported that the butterfly
stroke irritates her shoulders more than the other strokes. While
she denies painful popping or grinding within her shoulder, she
feels like her shoulders “slip out of place” when her hands enter
the water, especially during the butterfly stroke. She was also
having trouble with activities of daily living (reaching into the
back seat of her car while driving) and pain with her recently
added weightlifting training. Her symptoms were improved
with ice and rest from all training activities. e patient reported
the pain after practice would subside later in the day ranging
from a 1 to 3/10 and increase again at night when lying on her
shoulders. She reports SANE score on the right as 65/100 and
on left as 75/100.
She was a senior in high school and was offered scholarships
to swim in college. Nationals were scheduled in 2 weeks. She
was referred to physical therapy by her primary care physician
with a diagnosis of bilateral shoulder pain.
Review of systems
Systems review for yellow and red flag signs and symptoms,
conducted using OSPRO yellow flag and red flag tool
questionnaires, were negative. Aside from her shoulder pain,
she reported generally good health. She denied any nicotine,
alcohol, or drug use beyond non-steroidal anti-inflammatory
drugs to manage recent shoulder pain.
1.
What screening tool can be used to determine the patient’s
prognosis and designed to help select treatment pathway
based on risk for poor treatment outcome?
a. e Charlson Comorbidity Index.
b. e Keele STarT MSK Tool.
c. e OSPRO Red Flag screening tool.
d. e painDETECT.
e correct answer is b. e Keele STarT MSK Tool. e
tool is designed specifically to stratify intervention pathways for
patients with musculoskeletal conditions based on the likelihood
of persistent pain, disability, and poor treatment outcome.
Responses to the questionnaire are used to allocate patients into
prognostic risk categories (low, medium, high). e modified
painDETECT questionnaire for the shoulder is reliable and
sensitive to discriminate nociceptive from neuropathic pain.
e OSPRO is designed to detect red flags that may result in
a change in the patient care pathway but is not designed for
prognostication of interventions. e Charleson index is used to
categorize medical comorbidities and health risk stratification,
but not used to change the care pathway based on risk for poor
prognosis with interventions. is information is discussed in
the Level One: Screening portion of the monograph.
Tests and measures
e patient presented with increased thoracic kyphosis with
tight anterior shoulder musculature (decreased muscle length
of the pectorals and latissimus dorsi muscles) and depressed,
downwardly rotated scapula bilaterally. No impairments were
noted to the C5-T1 dermatomes on sensory testing. Reflexes
were bilaterally symmetrical and ROM for the cervical spine
and elbows were normal and pain-free. With palpation, pain
was reproduced on the anterior aspect of the shoulder and near
the greater tuberosity, but palpation of the acromioclavicular
joint and posterior shoulder musculature did not reproduce
symptoms. She had subtle atrophy of the supraspinatus and
infraspinatus muscles on the right greater than left noted with
palpation. e patient’s Beighton scale was 7/9. Shoulder active
ROM revealed normal motion bilaterally with mild pain at endrange elevation and combined hand behind the head functional
reaching. Passive ROM was normal with minimal pain at endrange with external rotation (ER) at 90° of abduction (120°
on the right and 115° on the left), bilaterally. Internal rotation
(IR) was normal (65° on the right, 72° on the left). Horizontal
adduction was normal with mild pain anteriorly on the right
greater than left.
Resisted tests for muscle performance were conducted using
a hand-held dynamometer to quantify maximal force output for
shoulder external and internal rotation. A ratio of make test
results comparing functional ER to IR on each side was created
to assess the athlete’s sport specific force production. e force
ratio (ER:IR) on the right was 0.26 (26%, with ER strength of
6 pounds compared to IR strength of 24 pounds), on the left
the force ratio was 0.44 (44%, with ER strength of 14 pounds
compared to IR strength of 32 pounds). e patient reported
increased fatigue with initial strength testing, which was her
familiar pain she has during her training. Strength tests for lower
trapezius and serratus anterior indicated weakness and increased
the patient’s sensation of fatigue and discomfort consistent with
her pain she reported with swimming (immediate post-practice
pain of 8/10 on the right and 7/10 on the left). Special testing
revealed a positive sulcus sign bilaterally; anterior shoulder pain
on the right greater than left with anterior apprehension, and
a reduction of pain with the relocation test bilaterally. Neer
and Hawkins impingement signs were positive bilaterally. e
patient had apprehension with the hyperabduction test at 115°
on the right and 110° on the left. e patient had a positive
anterior slide and negative compression rotation test results,
bilaterally.
2. Which history and examination results would be used to
rule in your top pathoanatomic diagnosis at this stage of
the exam?
a. Lag signs and symptoms used to rule in full-thickness
rotator cuff tear.
54
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b. Impingement signs and symptoms used to rule in
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subacromial pain syndrome.
c. Tests and symptoms used to rule in multidirectional
instability.
d. Tests and symptoms used to rule in a SLAP lesion.
e correct answer is c. Tests and symptoms used to
rule in multidirectional instability. e patient’s age, sex,
atraumatic mechanism of injury, and constellation of positive
signs and symptoms (reported “slip feeling” during the hand
entry phase of swimming, Beighton score of 7/9, and positive
hyperabduction test and anterior apprehension) raise the
likelihood of multidirectional instability (MDI) to the top of the
suspected pathoanatomic diagnosis. Positive impingement signs
are common in patients with glenohumeral joint instability,
associated with secondary impingement/subacromial pain
syndrome. e patient denies clicking and grinding, and overall
SLAP tests lack diagnostic value. e patient’s age (<40 years),
full active ROM, and ability to produce force in ER, substantially
reduce the likelihood of a large full-thickness rotator cuff tear
that are ruled in with lag signs. e examination findings used
to diagnose various shoulder pathologies are discussed in Level
Two: Specic Examination and Classication portion of the
monograph.
3.
What was an atypical finding identified in this patient
that may be of concern, warrant monitoring, and potential
referral?
a. Use of non-steroidal anti-inflammatories.
b. e SANE score.
c. Supraspinatus and infraspinatus atrophy.
d. Positive sulcus sign.
e correct answer is c. Supraspinatus and infraspinatus
atrophy. e patient had a significant decrease in ER
strength and mild muscle atrophy in both the supraspinatus
and infraspinatus musculature, bilaterally. All sensation and
reflexes are otherwise normal. A potential secondary hypothesis
attributed to these examination findings may be suprascapular
neuropathy. Alternatively, this presentation may also just be
due to pain severity, irritability levels, and poor training. e
examination findings of atrophy are discussed in Observation,
Level Two: Specic Examination and Classication portion of
the monograph. e SANE score and use of non-steroidal antiinflammatories can be used to monitor progress but is not a
current concern for referral. A positive sulcus sign is typical in
patients with MDI and is not used to monitor progress.
Further inquiry of the athlete’s training plan revealed
the absence of posterior rotator cuff strengthening exercises
and primary focus of shoulder IR strengthening and anterior
thoracic musculature as part of a new “dry land training
program” the athlete’s friend designed 8 weeks ago to help
prepare for Nationals.
Prognosis and plan of care
e patient’s overall prognosis for resolution of the
problems related to MDI are mixed with positive factors
including the short duration of her condition, habits related to
training on both dry land training and sport specific activities,
and her sport commitment and potential. e recent increase
in irritability, bilateral involvement, decreased strength and
endurance, mild atrophy, worsening function, and 2-week
timeline prior to an important competition seem to reduce the
likelihood of a quick recovery for this athlete. Given the short
duration of the patient’s symptoms coinciding with a change
in training program and the explained potential strength
imbalance, a trial of physical therapy was warranted with close
monitoring of strength for the supraspinatus and infraspinatus
muscles. Interventions matched to reduce shoulder pain
severity and irritability, strength and atrophy of the external
rotators, and ensure progression toward successful competition
in the short and long term was considered. Development of
a neuromuscular control program, similar to the Watson
program, and appropriate strength training program long-term
should restore functional goals long-term.
4.
Based on this patient’s objective evaluation what “concordant
sign” could help guide and evaluate the physical therapy
intervention plan?
a. Active shoulder ROM in ER or elevation.
b. Beighton scale.
c. Sulcus sign.
d. Repeated muscle performance testing.
e correct answer is d. Repeated muscle performance
testing. Primary movements that reproduce the patient’s
primary shoulder complaint should be used as a concordant
sign as discussed in Level Two: Specic Examination &
Classication, Concordant sign of the monograph. is athlete
experiences some end-range of motion discomfort but this was
not able to reproduce her primary complaint. Her primary
complaint occurred with repeated shoulder muscle testing and
perhaps endurance as increase in complaint was noted the more
testing was conducted. Strength and endurance are a requisite
to activities of daily living and swimming. Additionally,
muscle performance testing using a hand-held dynamometer
will assist with monitoring strength changes in ER, which is
warranted given the subtle atrophy noted of the supraspinatus
and infraspinatus muscles. e Beighton scale and Sulcus
sign are not expected to change with intervention. Range of
motion, while painful, is not the best concordant sign given the
hypothesized diagnoses.
Intervention
e patient’s care plan was focused on motor control
and glenohumeral joint stabilization exercises targeting
scapulothoracic, deltoid, and rotator cuff musculature. Activity
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55
and exercises were progressed as tolerated including the intensity
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and duration of the activity. Progression of loading and stress
was monitored to avoid producing increased pain or long-term
soreness. Based on the increased laxity associated with MDI,
this patient’s poor strength, impaired rotator cuff strength, and
the prolonged training and competition load, the ultimate focus
of this care plan was to improve motor control, muscle strength,
and overall upper extremity endurance. e intervention plan
was to see the patient 3 times in the 2 weeks prior to Nationals
for education, activity modifications, and activities to decrease
irritability; and 2 times per week for 8 weeks after Nationals.
•
Education: focused on clinical course of current problem
and relationship of physical therapy and home exercise
program goals to problem solution. Discussion on dry land
training program with weightlifting that includes shoulder
strengthening of the posterior rotator cuff.
e patient was able to continue with swimming with a
•
kickboard to emphasize lower extremity and core activity
while interventions matched to high irritability were initiated.
• Progressive exercise with focus on motor control and
principles from the Watson program was initiated. Cuing
was used to promote scapular control using elastic resistance
along the scapula to resist retraction with pain-free multiangle isometrics in ER and abduction starting in midROM progressing to end-ROM as tolerated. Focus for this
patient was isometrics at 50-75% of ER at 0° and 25-75%
of overhead elevation in the scapular plane in side-lying and
prone positioning. Progressed to 75-100% against gravity
isometric to active resistive activities and end-ROM holds.
•
e patient decided to forgo Nationals due to compromised
performance and she committed to a university athletic
scholarship starting in the fall.
Progression throughout full ROM with control of isometrics,
•
concentric, eccentric ROM in multiple planes. Exercise
progressions to progressively load the rotator cuff are outlined
in the Appendix.
• In 6 weeks, she was able to return to full training using pain
and response to exercises as guidelines of irritability levels.
• e patient’s SANE score was 95% bilaterally at discharge
from physical therapy at 10 weeks.
Case Scenario 3
History and interview
A 48-year-old right hand dominant female was referred for
physical therapy secondary to complaints of right lateral and
anterior shoulder pain and loss of motion and function (Penn
Shoulder Score: 27/100). She has had a history of shoulder pain
with lifting weights and competing in tennis in college over 15
years ago but has been pain free since. e patient reports an
approximate 1.5-month history of insidious onset of pain with
increased difficulty performing daily activities and pain now
that interferes with sleeping (pain ranges from 5 to 9/10). Her
pain reportedly increased with reaching to put on her seatbelt,
grooming her hair, and reaching behind her back. She used hot
showers to reduce her symptoms and has been avoiding using
the right arm. She denies any numbness, tingling, paresthesia,
or cervical symptoms. She has been unable to sleep due to her
shoulder pain over the last week and feels like her condition
was worsening. She works as a lawyer and has been under a
lot of stress recently with change in her firm’s ownership. Her
primary job responsibilities were computer work and lifting and
carrying files. e recent lack of sleep was making it difficult
to concentrate at work. She denies smoking, alcohol, or drug
use. She reports being referred by her primary care physician for
shoulder pain with radiographs showing mild acromioclavicular
joint osteoarthritis, but otherwise normal.
Based on the history alone, what is the predominant pain
1.
mechanism associated with this presentation?
a. Nociplastic.
b. Nociceptive.
c. Neuropathic.
d. Chronic.
e correct answer is b. Nociceptive. Given the local
pattern, short duration of symptoms, mechanical nature with
pain that worsens with activity and eases with rest, nociceptive
pain is most likely. Predominant neuropathic shoulder pain
tends to follow a radicular pattern (for example, cervical
C5 radiculopathy) that is located along the upper arm or in
other locations specific to a peripheral nerve (for example,
suprascapular neuropathy) distribution and could potentially be
reproduced with neurodynamic tests. Predominant nociplastic
pain tends to be diffuse, potentially beyond the shoulder
region, in anatomic areas non-characteristic of shoulder pain.
With nociplastic pain, there may also be disproportionate
aggravating and easing pain responses and diffuse areas of
tenderness with palpation. While the patient has symptoms of
high psychological stress, the nociceptive presentation is clear
with the history. Examination findings will further clarify.
Information regarding pain mechanisms can be found in the
History and Interview portion of the monograph.
2.
What screening tool may be helpful with this patient as a
validated tool to discriminate nociceptive from neuropathic
shoulder pain?
a. e OSPRO-Yellow Flag screening tool.
b. e modified painDETECT for the shoulder.
c. e Charlson Comorbidity Index.
d. e Keele STarT MSK Tool.
e correct answer is b. e modified painDETECT for
the shoulder. e modified painDETECT questionnaire for
the shoulder is reliable and sensitive to discriminate nociceptive
from neuropathic pain. e OSPRO is a screening tool designed
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to detect yellow flags, not pain presentation. e Charleson
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index is used to categorize medical comorbidities and assist
with need for referral and health risk stratification. e Keele
STarT MSK Tool is designed specifically to stratify intervention
pathways for patients with an assortment of musculoskeletal
conditions based on the likelihood of a poor prognosis (low,
medium, high) with persistent pain and disability. is
information is discussed in the Level One: Screening portion of
the monograph.
Review of systems
A systems review for yellow and red flag signs and
symptoms was conducted using OSPRO yellow flag and red flag
tool questionnaires. In addition to overall physical and mental
health, the patient was screened for cancer history. She reported
Type II diabetes and seasonal allergies. She reports her diabetes
(Type II) had been well controlled with diet, medication
(Glucophage), and exercise. She was using non-steroidal antiinflammatory medications to manage this episode of shoulder
pain, without much success.
Tests and measures
Movement observation revealed compensation to take off
her garments with decreased motion in the right shoulder. Her
upper extremity was held in internal rotation (IR) with forward
head and increased thoracic kyphosis. ere was no impairment
to static cutaneous sensation in the upper extremity dermatomes.
Deep tendon reflexes appear bilaterally symmetrical and range
of motion (ROM) in cervical spine and elbows were normal and
pain free. ere was limited active and passive ROM for wrist
extension to 20° and flexion to 40° on the right, but no pain.
Left wrist ROM was normal. Shoulder active ROM in forward
elevation was painful and limited to 60° with excessive scapular
motion/substitution on the right; forward elevation was non
painful and 161° on the left; external rotation (ER) at the side
on the right was painful at 35° compared to 65° and pain free on
the left. Functional IR up the back was to the posterior superior
iliac spine on the right compared to T10 on the left.
3.
What test results would be most useful to rule in your top
pathoanatomic diagnosis at this stage of the examination?
a. Neer and Hawkins signs for subacromial pain syndrome.
b. Scapular reposition and assistance tests for subacromial
pain syndrome.
c. Lag signs for full-thickness rotator cuff tear.
d. Passive range of motion for primary adhesive capsulitis.
e correct answer is d. Passive range of motion for
primary adhesive capsulitis. Given the patients age, sex,
prior shoulder pain, insidious onset of this episode, loss of
active ROM in multiple planes of motion, and pain interfering
with sleep, competing pathoanatomic diagnoses would be
subacromial pain syndrome or primary adhesive capsulitis.
Passive ROM assessment would provide the most information
on a diagnosis at this stage of the examination. A loss of ER
makes the diagnosis of primary adhesive capsulitis more likely
and end-feels are used to classify stage of irritability. Subacromial
impingement syndrome is plausible, but the positive Neer and
Hawkins signs alone do not have diagnostic accuracy to be
used to rule in or out subacromial pain syndrome. Scapular
reposition and assistance tests provide information related to
the movement problem and prognosis, not a diagnosis. Lag
signs would be diagnostic of a full-thickness rotator cuff tear,
but given the patient’s age and insidious onset, this is less likely.
Diagnostic utility of examination findings is discussed in Level
Two: Specic Examination & Classication of the monograph.
Passive ROM was limited in all planes on the right with
ER at 10° at the side, forward elevation to 75°, and abduction
to 60°. All motions were limited by pain and guarding. Resisted
tests for strength in abduction and ER were strong but painful.
ere was a negative sulcus sign bilaterally. e suspected
pathoanatomic diagnosis is primary adhesive capsulitis, likely
stage II, with shoulder pain and mobility being the primary
associated impairments and intervention was initiated.
Prognosis and plan of care
e patient’s overall prognosis for resolution of the adhesive
capsulitis is mixed with positive factors including the short
duration of her condition and her lifestyle factors including
consistent exercise and no known negative coping strategies.
e recent increase in symptom severity, irritability, and
worsening function along with her Type II diabetes are cause
for concern. e interventions included providing education
regarding the expected course of the condition and approach
to restoring mobility and decreasing pain. Manual techniques
were performed to prepare the joint for stretching and decrease
irritability level. erapeutic exercises that encourage improved
joint mobility within the tolerance of the patient’s glenohumeral
joint irritability level were prescribed. e patient was instructed
to institute a consistent daily home exercise program (HEP)
encouraging frequent stretching, mobility, and use of her arm
during home and work activities throughout the day.
Intervention
• e initial treatment included the provision of examination
and evaluation, educational discussion regarding the clinical
course of the condition, need for consistent use and mobility
of the glenohumeral joint daily to promote functional ROM
and decrease irritability.
• Low grade posterior mobilization of the shoulder and
distraction, followed by performance of pendulum exercises
and active assistive forward elevation to promote mid- to endROM stretching with less pain.
• e patient’s HEP was very specific to perform passive and
active assistive exercise for mobility within low to moderate
pain levels that would not exacerbate symptoms. e
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direction of stretching was focused on elevation and rotation.
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Frequent short bouts of stretching and mobility exercises
were encouraged. e plan for subsequent visits was focused
on gaining ROM and function.
After 1 week, the patient returned with continued
complaints of severe pain, continued loss of motion, and
expressed increased problems related to sleep and work. She
wanted to know if anything else could be done to help ease the
pain and improve her sleep, while acknowledging her acceptance
that the problem will likely take time to resolve.
4. What is the most appropriate next step to help the patient
with primary adhesive capsulitis in the short term to relieve
pain and loss of motion, particularly in stage II and high
irritability?
a.
Discuss the patient’s willingness to be referred for intraarticular injection combined with physical therapy
focus on mobility exercises.
Order a transcutaneous electrical nerve stimulator
b.
(TENS) unit to be used in combination with physical
therapy focus on mobility exercises.
Have the patient perform aerobic activity before
c.
mobility exercises.
d.
Perform high-grade joint mobilizations combined with
mobility exercises.
e correct answer is a. Discuss the patient’s willingness
to be referred for intra-articular injection combined with
physical therapy focus on mobility exercises. In the Level
ree: Rehabilitation Classication & Matched Interventions,
Adhesive capsulitis portion of the monograph, there is strong
evidence (level I) to support intra-articular injections combined
with mobility exercise to improve pain and mobility in the short
term for patients with primary adhesive capsulitis. While aerobic
exercise and TENS are used for pain relief, an intra-articular
injection has high-level evidence to support its effectiveness.
Additionally, evidence shows high-grade mobilization and
painful terminal ROM mobility exercises are less effective than
education and exercises alone. Given the difficulty sleeping
despite efforts to modify position and a trial of physical
therapy, a discussion of the patient’s willingness to consider a
consultation for intra-articular injection is warranted.
e patient was referred to an orthopaedic surgeon and
received an intra-articular injection in the right shoulder. e
pain severity had decreased so that she was able to perform
mobility exercise to end ranges of glenohumeral motion with
less residual pain. e patient was treated 2 visits per week for
2 weeks followed by 1 visit per week for 3 weeks with a Penn
Score of 81/100 after 12 weeks. e patient was transitioned
to a progressive HEP for the subsequent 6 weeks with 1 visit
every 3 weeks. e patient was discharged following 14 physical
therapy visits over a 16-week period with a Penn Score of
92/100.
Case Scenario 4
History and interview
A 19-year-old female collegiate soccer player (goalie) was
injured 1 week ago during practice when reaching laterally to
block a pass and then falling on her dominant right shoulder.
She heard a “pop” and felt her shoulder “come out” when
landing on the arm to brace her fall. She had immediate pain in
the right shoulder as well as pain that extended down the arm.
When she stood up, she felt her shoulder “pop back in.” She
was evaluated off the field and sent immediately to the urgent
care where radiographs were ordered and read as negative
for a fracture. She was given a sling and a referral to physical
therapy. at evening, she noticed numbness and paresthesia
in her arm that has persisted. Her past medical history includes
a right shoulder subluxation in high school; treated with
physical therapy with full recovery. She has exertional asthma
that is controlled with an inhaler. She has a history of anxiety
and depression treated with anti-depressants and continued
counseling through university services. e Western Ontario
Shoulder Instability Index (WOSI) scored at 25% and she gave
a Single Assessment Numeric Evaluation (SANE) score of 30%
for her right shoulder.
1. What is the most likely associated complication following a
first time glenohumeral joint dislocation in this 19-year-old
athlete that may require a change in care pathway/referral?
a. Biceps lesion.
b. Bony Bankart lesion.
c. Brachial plexus injury.
d. Rotator cuff tear.
e correct answer is c. Brachial plexus injury. is is
discussed in Level ree: Rehabilitation Classication & Matched
Interventions, Traumatic dislocation portion of the monograph.
Brachial plexus injuries have been reported to occur in 18-71%
of shoulder dislocations, primarily affecting the axillary nerve,
and most neuropraxia and axonotmesis resolve spontaneously in
the majority of patients. Patients with more severe nerve injuries
following a dislocation will not follow the same clinical care
pathway of those without. A referral to a specialist is warranted
in patients with significant motor loss or progressive weakness
for nerve conduction velocity and electromyography testing.
Fractures, bony Bankart lesion, and rotator cuff tears are more
common in adults over the age of 40 years. Biceps lesions are
not a common complication following an anterior dislocation.
Systems review
A review of systems of yellow and red flags was completed
and the patient was deemed appropriate for further examination.
Test and measures
e patient presented with the right upper extremity in
a sling. Upon removal of the sling, the right arm was held in
58
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