- The document discusses shoulder pain and frozen shoulder. Frozen shoulder progresses through painful freezing and frozen stages as the shoulder capsule becomes inflamed and stiff, limiting range of motion. - It presents a case of a 48-year-old male with left shoulder pain for 2 months. Exam finds decreased range of motion and pain with abduction. Treatment includes acupuncture at points like ST38 and SI4 to relieve pain and increase range of motion. - The stages of frozen shoulder - freezing, frozen, and thawing - are described as the condition progresses from increasing pain and stiffness to gradual improvement in motion over 6 months to 2 years.

1. Shoulder Pain
Donna Guthery
AOMA Graduate School of Integrative
Medicine 2014

2. Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

3. Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

4. In frozen shoulder, the smooth tissues of the shoulder
capsule become thick, stiff, and inflamed.
http://orthoinfo.aaos.org/topic.cfm?topic=a00071

5. Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

6. See Hand out
Left Shoulder Pain

7. HPI
• 48 Yom accountant, former swimmer, Shoulder pain x 2 months
• No pain at rest, pain with abducting Left arm
• Achy, non radiating 6-7/10 with movement only, no numbness or
tingling
• Pain over anterior and medial deltoid muscles
• Wakes him at night if arm is too adducted
• Ibuprofen 800 mig bid, not much relief, PT exercises
• Also h/o upper back pain x years, achy non radiating, comes
and goes

8. Exam
• 110/68, p: 66 rr: 18, AA, O x 3
• L shoulder ROM decreased, abduct to 30-40 º pain is 6/10 with
movement, able to internally externally rotate at lesser degree,
uses accessory muscles when attempting abduction
• Can place L arm behind back but unable to raise it to scapula
• Unable to assess resisted ROM d/t pain
• Shrugs shoulders without pain

9. neck
• Rom 75º ish bil, flexion/ extension ok, some tension with flexion
chin to chest
• Lateral flexion shoulder to ear no pain
• Few myofascial knots bil splenius capitus C 2-5, levator scapula
tension, large myofascial knot R medial trapezius
• Motor strength: 5/5 bil hand grasp, RUE 5/5 C 5-8, LUE C 5/6
difficult to assess d/t pain

10. Treatment
• Initially St 38 L and passive ROM with traction able to abduct L
arm 10º more
• Added SI 4, SJ 5 , Lu 6, 7, LI 4 on Left with local trigger points
• GB 20 bil./e SI 13 bil/e, SI 10, 11,12 L, JJ C3 bil, C 5 bil, C 6 bil,
T 1 bil, T 2 bil, T 3 bil,Jianqian L x 30 minutes using micro
current
• Followed by cupping massage
• End of treatment: able abduct L arm to 80 degrees
• Rec: twice a week for two weeks, if responding well, once a
week and re-eval prior/after to each tx for follow up

11. Freezing
In the "freezing" stage, slowly have more and more pain.
As the pain worsens, shoulder loses range of motion.
Freezing typically lasts from 6 weeks to 9 months.
Frozen
Painful symptoms may actually improve during this stage,
but the stiffness remains. During the 4 to 6 months of the
"frozen" stage, daily activities may be very difficult.
Thawing
Shoulder motion slowly improves during the "thawing"
stage. Complete return to normal or close to normal
strength and motion typically takes from 6 months to 2
years.
http://orthoinfo.aaos.org/topic.cfm?topic=a00071

12. Examination
• Pain scale 0 – 10/10
• May find tenderness at bicipital groove
• May also have pain in upper back and neck d/t overuse of
shoulder girdle muscles
• At rest may brace affected extremity against body
• Assess alignment of bones and soft tissues
• Assess postural alignment of cervical, thoracic, lumbar and
humeral/scapular position (may find head forward, protracted scapula
and thoracic kyphosis)
Brigham and Women’s Hospital Inc. Dept. of Rehabilitation
Services 2010

13. Differential Diagnoses
 Biceps Rupture
 Biceps Tendinopathy
 Brachial Neuritis
 Cervical Disc Disease
 Cervical Myofascial Pain
 Cervical Spondyliosis
 Cervical Sprain and Strain
 Complex Regional Pain Syndromes
 Heterotopic Ossification
 Myelomeningocele
 Neoplastic Brachial Plexopathy
 Parkinson Disease
 Psoriatic Arthritis
 Rheumatoid Arthritis
 Rotator Cuff Disease
 Shoulder and Hemiplegia
 Thoracic Outlet Syndrome
 Traumatic Brachial Plexopathy
http://orthoinfo.aaos.org/topic.cfm?topic=a00071

14. Muscle Origin on scapula Attachment on humerus Function Innervation
Supraspinatus
muscle
supraspinous fossa
superior and middle
facet of the greater
tuberosity
abducts the arm
Suprascapular nerve
(C5)
Infraspinatus
muscle
infraspinous fossa
posterior facet of
the greater tuberosity
externally rotates the
arm
Suprascapular nerve
(C5-C6)
Teres minor muscle
middle half of lateral
border
inferior facet of
the greater tuberosity
externally rotates the
arm
Axillary nerve (C5)
Subscapularis
muscle
subscapular fossa
lesser
tuberosity (60%)
or humeral neck(40%)
internally rotates the
humerus
Upper and Lower
subscapular nerve
(C5-C6)
http://orthoinfo.aaos.org/topic.cfm?topic=a00071

15. Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

16. Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

17. FINDING PROBABLE DIAGNOSIS
Scapular winging, trauma, recent viral illness Serratus anterior or trapezius dysfunction
Seizure and inability to passively or
actively rotate affected arm externally
Posterior shoulder dislocation
Supraspinatus/infraspinatus wasting Rotator cuff tear; suprascapular nerve
entrapment
Pain radiating below elbow; decreased
cervical range of motion
Cervical disc disease
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation.
AM Fam Physician, 2000

18. Shoulder pain in throwing athletes;
anterior glenohumeral joint pain and
impingement
Glenohumeral joint instability
Pain or “clunking” sound with overhead
motion
Labral disorder
Nighttime shoulder pain Impingement
Generalized ligamentous laxity Multidirectional instability
Woodward MD, T. & Best MD, T. The painful shoulder: Part I.
Clinical evaluation. AM Fam Physician, 2000

19. Apley scratch test. The patient attempts to touch the opposite scapula
to test range of motion of the shoulder. (Left) Testing abduction and
external rotation. (Right) Testing adduction and internal rotation.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation.
AM Fam Physician, 2000

20. Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation.
AM Fam Physician, 2000
Supraspinatus examination (“empty can” test). The patient
attempts to elevate the arms against resistance while the
elbows are extended, the arms are abducted and the
thumbs are pointing downward.

21. Infraspinatus/teres minor examination. The patient
attempts to externally rotate the arms against resistance
while the arms are at the sides and the elbows are flexed
to 90 degrees.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation.
AM Fam Physician, 2000

22. TEST MANEUVER
DIAGNOSIS SUGGESTED
BY POSITIVE RESULT
Apley scratch test Patient touches superior and
inferior aspects of opposite
scapula
Loss of range of motion:
rotator cuff problem
Neer's sign Arm in full flexion Subacromial impingement
Hawkins' test Forward flexion of the
shoulder to 90 degrees and
internal rotation
Supraspinatus tendon
impingement
Drop-arm test Arm lowered slowly to waist Rotator cuff tear
Cross-arm test Forward elevation to 90
degrees and active
adduction
Acromioclavicular joint
arthritis
Spurling's test Spine extended with head
rotated to affected shoulder
while axially loaded
Cervical nerve root disorder
Apprehension test Anterior pressure on the
humerus with external
rotation
Anterior glenohumeral
instability
Relocation test Posterior force on humerus
while externally rotating the
arm
Anterior glenohumeral
instability
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam

23. Sulcus sign Pulling downward on elbow
or wrist
Inferior glenohumeral
instability
Yergason test Elbow flexed to 90 degrees
with forearm pronated
Biceps tendon instability or
tendonitis
Speed's maneuver Elbow flexed 20 to 30 degrees
and forearm supinated
Biceps tendon instability or
tendonitis
“Clunk” sign Rotation of loaded shoulder
from extension to forward
flexion
Labral disorder
Woodward MD, T. & Best MD, T. The painful shoulder: Part I.
Clinical evaluation. AM Fam Physician, 2000

24. 08
Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

25. Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

26. Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

27. Burbank et al, Chronic shoulder pain part I, Am Fam Physician
2008

28. Hawkins' test for subacromial impingement or rotator cuff
tendonitis. The arm is forward elevated to 90 degrees,
then forcibly internally rotated.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I.
Clinical evaluation. AM Fam Physician, 2000

29. Cross-arm test for acromioclavicular joint disorder. The
patient elevates the affected arm to 90 degrees, then
actively adducts it.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I.
Clinical evaluation. AM Fam Physician, 2000

30. Apprehension test for anterior instability. The patient's arm
is abducted to 90 degrees while the examiner externally
rotates the arm and applies anterior pressure to the
humerus.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I.
Clinical evaluation. AM Fam Physician, 2000

31. Yergason test for biceps tendon instability or tendonitis.
The patient's elbow is flexed to 90 degrees, and the
examiner resists the patient's active attempts to supinate
the arm and flex the elbow
Woodward MD, T. & Best MD, T. The painful shoulder: Part I.
Clinical evaluation. AM Fam Physician, 2000

32. Sulcus test for glenohumeral instability. Downward traction
is applied to the humerus, and the examiner watches for a
depression lateral or inferior to the acromion.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I.
Clinical evaluation. AM Fam Physician, 2000

33. Spurling's test for cervical root disorder. The neck is
extended and rotated toward the affected shoulder while
an axial load is placed on the spine.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I.
Clinical evaluation. AM Fam Physician, 2000

34. LIGAMENT
S OR
JOINT GRADE 1 GRADE 2 GRADE 3 GRADE 4 GRADE 5 GRADE 6
Acromiocla
vicular
ligaments
Sprained Disrupted Disrupted Disrupted Disrupted Disrupted
Acromiocla
vicular
joint
Intact Disrupted or
slight
vertical
separation
Disrupted Disrupted Separated Ruptured
Coracoclav
icular
ligaments
Intact Sprained Disrupted or
slight
vertical
separation
Disrupted Disrupted Disrupted
Woodward MD, T. & Best MD, T. The painful shoulder: Part II.
Clinical evaluation. AM Fam Physician, 2000

35. IMAGING MODALITY ADVANTAGES DISADVANTAGES
MRI 95% sensitivity and specificity
in detecting complete rotator
cuff tears, cuff degeneration,
chronic tendonitis and partial
cuff tears
Often identifies an apparent
“abnormality” in an
asymptomatic patient
No ionizing radiation
Arthrography Good at identifying complete
rotator cuff tear or adhesive
capsulitis (frozen shoulder)
Invasive
Relatively poor at diagnosing a
partial rotator cuff tear
Ultrasonography Accurately diagnoses complete
rotator cuff tears
Less useful in identifying partial
cuff tears
Operator-dependent
interpretation
MRI arthrography Reliably identifies full-thickness
rotator cuff tears and labral
tears
Invasive
CT scanning May be useful in diagnosis of
subtle dislocation
Ionizing radiation

36. RADIOGRAPH ABNORMALITY BEST VISUALIZED
AP view of glenohumeral joint Degenerative glenohumeral changes
AC joint AC degenerative changes
AC joint separation
Distal clavicle fracture
Axillary lateral view of shoulder Glenohumeral dislocation
Bony Bankart lesion*
Supraspinatus outlet (arch) Abnormality of acromion process
Degenerative changes of anterior acromion
Woodward MD, T. & Best MD, T. The painful shoulder: Part I.
Clinical evaluation. AM Fam Physician, 2000

37. Burbank et al, Chronic shoulder pain part I, Am Fam Physician
2008

38. References
Burbank MD, K., Stevenson MD, J, Czarnecki DO, G. &
Dorfman, DO, J. Chronic shoulder pain: Part I. evaluation and
diagnosis. Am Fam Physician. 2008 Feb 15:77(4):453-460.
Burbank MD, K., Stevenson MD, J, Czarnecki DO, G. &
Dorfman, DO, J. Chronic shoulder pain: Part II. Treatment.
Am Fam Physician. 2008 Feb 15:77(4):493-497.
Cheng, I. 2013 Thawing frozen shoulder-A case study and
clinical recommendations for the use of acupuncture in
treatment of adhesive capsulitis. The American Acupuncturist
V62, 25-29.

39. Deily DC, S. 2013 Class Notes
Hammer, D. 2012. Chinese scalp acupuncture relieves
pain and restores function in complex regional pain syndrome.
Military Medicine, vol. 177, Oct 2012.
He, D., Hostmark, A., Viersted, K., & Medbo, J. 2005.
Acupuncture in Medicine. 23(2):52-61.
Ma, T., Kao, M., Liu, I., Chiu, Y., Chien, C., Ho, T., Chu,
B. and Chang, Y. 2006. A study on the clinical effects of
physical therapy and acupuncture to treat spontaneous frozen
shoulder. The American Journal of Chinese Medicine, Vol. 34,
NO 5, 759-775.
Peilin, S. 2011. The Treatment of Pain with Chinese
Herbs and Acupuncture, Churchill Livingstone, Edinburgh.