Assessment & Management of the Shoulder in Private Physiotherapy Practice

1. Assessment & Management
of the Shoulder in Private
Physiotherapy Practice
Ullswater Physiotherapy &
Sports Injuries Clinic CPD
Mary McCance MSc. BSc
(Hons). BSc (Hons). MCSP
Sat 15th Feb 2020

2. Let’s learn more about the
shoulder!
• Shoulder pain / stiffness / instability is the second most
common presentation I see in clinical practice after back
pain
• I see mainly sports / occupational injuries among active
populations
• Some of these people will have been seen by multiple
practitioners often with varying diagnoses and
treatments
• Some will have Coaches / PTs
• Some will be at first contact

3. Common presentations in
clinical practice
• Painful shoulder – Painful arc, pain with activities above
shoulder height, pain with driving, pain lying on the affected
side, pain with HBB (hand behind back)
• Stiff shoulder Usually lacking range into flexion/extension,
abduction and/or internal/external rotation
• Unstable shoulder the patient will tell you it feels unstable,
painful clunks and clicks
• Weak shoulder muscle atrophy noted with weakness on
resisted / functional tests possible possible winging of the
scapula
• Or a combination of these

4. Common Causes of Pain
• The primary sources of pain are:
• 1. Glenohumeral joint, including the articular labrum,
the biceps and the capsule
• 2. Subacromial area, rotator cuff, the bursa and the
acromion
• 3. AC joint, including the articular meniscus

5. Normal Shoulder
Anatomy

6. Ligaments

7. Glenoid Labrum

8. Rotator Cuff Anatomy

9. Scapulothoracic anatomy

10. Anterior view

11. Force Couples of the
Shoulder
Two separate force
couples are of particular
importance in motion of
the shoulder complex. The
trapezius and serratus
anterior act together to
produce upward rotation of
the scapula. If one or more of
these muscles is weak or
dysfunctional this can lead to
impingement.

12. Force Couples
The rotator cuff acts in concert
with the deltoid to move the arm
above head. One of the actions
of the deltoid is to lift your arm
over your head. One of the
actions of the 4 rotator cuff
muscles works to depress the
humerus. The deltoid is bigger
and stronger than the rotator
cuff. With a weak rotator cuff,
the deltoid can easily win this
force battle and begin to elevate
the humeral head too far.
Leading to impingement.

13. Some possible underlying
causes of pain
• Rotator cuff pathology – painful arch / impingement –
internal/external impingement
• Bursitis – fluid filled sac
• Glenohumeral instability - history of dislocations
• Labral tears
• Biceps related pathology - SLAP tears / tendinopathy
• Posterior shoulder stiffness (GIRD)
• Scapular pathology
• Adhesive capsualitis (frozen shoulder)
• Calcific Tendonitis
• ACJ / SCJ

14. How I assess the shoulder
• History taking
o How / when did it start / mechanism of injury
o Any history of trauma / red flags / yellow flags
o Location of symptoms / body chart
o Any pins and needles / numbness
o Aggravating factors / what makes it worse
o Easing factors / what makes it better
o Sleep
o Worse, better, staying the same
o Any other injuries
o Medical history / meds
o Create Problem list
o Assess goals

15. Objective Examination
• Visual check deformity / bruising / swelling
• Observe patient undressing for examination
• Always check the neck first AROM / PROM
• Active range of movement (AROM) include thoracic
spine
• Passive range of movement (PROM)
• Resisted tests
• Grip strength hand held dynamometry
• Always assess the other arm
• Special tests

16. Special Tests
• The following tests are just a brief sample of the many
tests of the shoulder
• The various tests presented are not a sure fire way of
diagnosing pathology
• Multiple pathologies can and do coexist
• It is impossible to isolate and test single structures
• Findings must be seen in the context of a thorough
history
• Imaging of the shoulder may be required
• The most accurate way to diagnose shoulder pathology
is through arthroscopy

17. Special Tests
• Posterior Capsular tightness GIRD Good Starting point.
Often seen in overhead athletes / occupations. Posterior
capsular tightness leads to anterosuperior translation of
humeral head in flexion. Can lead to impingement of
subacromial space
•

18. Special Tests
• Neer’s Impingement Test Designed to reproduce
symptoms of rotator cuff impingement under the
corocoacromial arch through flexing the shoulder and
applying pressure. Symptoms should be reproduced if
there is a problem with the supraspinatus or biceps. This
test is also associated with the Hawkin’s Kennedy Test
• A positive test may be due to other causes such as ACJ
pathology

19. Special Tests
Neer’s impingement sign is
elicited when the rotator cuff
tendons are pinched under the
coracoacromial arch. The test is
performed by placing the arm in
forced flexion with the arm
pronated. The scapula should be
stabilised to prevent
scapulothoracic motion. Pain is a
sign of subacromial
impingement.
• Neer’s impingement Test

20. Special Tests
• Hawkin’s Kennedy Test designed to reproduce patients
symptoms and infers impingement. Less reliable than
Neer’s Test. Indicative of impingement between the
greater tuberosity of the humerus against the coraco-
humeral ligament, trapping all those structures which
intervene.

21. Special Tests
• Apprehension Test. Testing anterior instability.
Designed to recreate apprehension and the feeling that
the joint is vulnerable. In supine or sitting the arm is
positioned in 90° abduction and external rotation. With
increasing external rotation the examiner watches for
apprehension on the part of the patient.

22. Special Tests
Apprehension Test
Essentially this test must produce
an apprehension response from
the patient. Pain alone does not =
a positive test. In the case of a
positive test then proceed to the
relocation test.

23. Special Tests
• Jobe’s Relocation Test Most sensitive test to determine
the presence of anterior instability especially in the face
of secondary impingement. The examiner performs the
apprehension test and notes the amount of external
rotation before the onset of apprehension. They then
return to the start position and apply a posterior stress
over the humeral head. They then repeat external
rotation and again note amount of external rotation at
onset of apprehension.

24. Special Tests
Jobe’s Relocation Test
Jobe proposed that the
anteriorly directed force
tends to compress the
rotator cuff tendon between
the greater tuberosity and
the posterior superior
region of the glenoid rim;
thus patients with minor
instability will experience
pain but not apprehension.

25. Special Tests
• O’Brian’s Test For SLAP tears / ACJ.
The patient is instructed to flex their
arm to 90° with the elbow fully
extended and then adduct the arm
10-15°medial to sagittal plane. The
arm is then maximally internally
rotated and the patient resists the
examiner's downward force. The
procedure is repeated in supination.
The O'Brien Test is designed to
maximally load and compress the
ACJ and superior labrum. For
maximal results the authors stress
that the patient should resist the
examiner's downward force rather
than the examiner resisting forward
flexion.

26. Special Tests
• Scarf Test designed to test the ACJ
the 90 degrees flexed arm on the
affected side is forcibly adducted across
the chest. It is essential that the patient
reports the pain as being specifically
over the AC joint with this test for a
positive test. It is common to feel
posterior capsule stretch pain with the
test (false positive). An injury to the AC
joint is typically sustained from a direct
fall on the point of the shoulder. The
injury may range from a torn meniscus
of the joint to a complete dislocation .

27. Clinical Reasoning

28. Management of the
Shoulder
• Should we treat? When to refer
• Exercise selection & Rehabilitation plan
• Manual techniques acupuncture / massage / rock blades
• Return to sports / previous activities
• Monitor / adapt / progress goals
• Liaise with other professionals. Private / NHS / PTs

29. Rehab Exercises
• Passive mobility pulley work / cane
• Auto assisted cane / stick / TRX
• Active mobility work through all ranges
• Resistance exercises isometrics / concentrics / eccentrics
• Proprioception exercises
• Closed chain / weight bearing
• Open chain
• Whole kinetic chain / functional rehab
• Sport / work specific drills
• Goal driven rehabilitation
• See Physiotools sheet for rehab ideas

30. Rehab Exercises
• Select exercises and reps/sets according to
o Assessment findings
o Patient’s ability / pain levels
o Patient’s time constraints
o Patients sport / occupation
o Patient’s goals
o Equipment available
o Space available
o Time available

31. Rehab Exercises
• Resistance exercise is an important component of
effective rehab programmes, but the optimal level of
resistance remains unclear. Pain and/or fatigue can be
used to guide treatment prescription, but whether pain
should be produced or avoided during exercise is not
clear.
• Higher doses of exercises might confer superior
outcomes, and should be maintained for at least 12
weeks before a decision regarding the potential for
surgery is taken.

32. Shoulder Tendons
• Some studies advocate surgery for tendinopathies after
3–6 months of conservative management.
• Recent research has demonstrated that outcomes after
tendon loading exercises both up to 12 months and
longer term are as good as surgery, at least for shoulder
tendinopathy.
• It suggested healthcare professionals who treat patients
with tendinopathies should reserve surgery for selected
cases and only after a sufficiently long course (12
months) of evidence-based loading exercise has failed.

33. Outcome Measures
• DASH / Quick DASH questionnaires
• Functional measures HBB / driving / bench press
• Hand Held Dynamometry grip strength
• 10 rep max of a relevant exercise or anywhere
• 1 rep max of a relevant exercise in between
• Pain 0-10 scale
• RPE scale
• Sleep

34. To Close
• The shoulder complex is complex but assessment,
management and rehabilitation can follow some simple
principles.
o Treat the patient as a whole person both physically and mentally
o Refer as required. Initially if concerned or other investigations are required, or If
not improving after a month or so of good quality rehab refer the patient to their
GP
o Exercise is the corner stone of treatment for Physiotherapy / rehab
o Work with other professionals where possible Consultant / GP / Physio / PT /
Sports Therapist
o Always listen to the patient how they are feeling / coping with exercises and
rehab. Provide opportunities for discussion
o Be progressive and goal driven
o Expect setbacks

35. References
• Brukner & Kahn (2017) Clinical Sports Medicine (5th edition).
McGraw & Hill Education. Australia.
• Challoumas et al (2019) How does surgery compare to sham
surgery or physiotherapy as a treatment for tendinopathy? A
systematic review of randomised trials. BMJ Open Sport Exer
Medicine. doi:10.1136/bmjsem-2019-000528
• Funk et al (2020) Sports Injuries of the Shoulder. Springer.
Switzerland.
• Littlewood et al (2015) Therapeutic Exercise for Rotator Cuff
tendinopaty: a Systematic Review of Contextual Factors and
Prescription Parameters. International Journal of Rehabilitation
Research. DOI: 10.1097/MRR.0000000000000113
• www.assignmentfirm.com/cna253-255-clinical-reasoning.php
• www.pintrest.co.uk
• www.physio-pedia.com
• www.shoulderdoc.co.uk

36. Abbreviations
• ACJ Acromioclavicular Joint
• AROM Active Range of Movement
• PROM Passive Range of Movement
• GHJ Glenohumeral Joint – ball & socket joint
• GIRD Glenohumeral Internal Rotation Deficit
• HBB Hand Behind Back
• RPE Rating of Perceived Exertion
• SLAP Superior Labrum Anterior Posterior lesions of the
glenoid labrum.
• STJ Sternoclavicular Joint
• TRX Total Resistance eXercise suspension training