Physical Therapy Management
of Shoulder Pain
Jill Hipskind, PT, DPT, OCS, CSCS, CMT
Rock Valley Physical Therapy
What should trigger a
referral to PT from PCP?
• Complaints of musculoskeletal shoulder pain
• Complaints of ROM limitations
• Complaints of upper extremity weakness
• Inability or difficulty performing ADLs
• Inability or difficulty performing work-related
tasks/activities
• Inability or difficulty performing recreational activities
Initial Physical Therapy Evaluation
#1 priority – make sure patient is appropriate for
PT and symptoms are musculoskeletal in nature
Initial Evaluation
(cont)
Determine if symptoms are from a local source
or proximal referral (cervical spine)
Initial Evaluation —
Subjective
• Duration of Current Episode
• Mechanism of Injury
• Description and Location of Symptoms
• Latency of Symptoms
• Aggravating and Relieving Positions/Activities
• 24-Hour Pattern
• Functional Limitations
Initial Evaluation —
Subjective
• Current or Previous Treatment
• History of Previous Shoulder Problems
• History of Cervical Spine Problems
• Past Medical History
• Functional Outcome Tool
Initial Evaluation —
Objective
Observation of Posture
Vitals
Neurological Examination
Cervical Spine Screen
Shoulder Assessment
– AROM
– PROM
– Strength
– Special Tests
– Joint Mobility—AC, SC, ST, GH
– Neural Mobility Screen
• Quick screen of distal joints
• Thoracic Spine Mobility
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Differential Diagnosis/
Pattern Recognition
• Rotator Cuff Pathology/Dysfunction
– Difficulty laying on shoulder and difficulty sleeping
– Painful/limited AROM (PROM may or may not be impaired)
– Lateral upper arm pain
– Functional limitations with overhead activities & ADLs, such as:
fastening bra behind back, tucking in shirts, don/doff shirts or
jackets
– Special Tests: Empty can test, Drop arm test, Hornblower’s,
Lift-off, Bear Hug Test, or Belly Press Test
• Subacromial Impingement/Bursitis
– See above
– Special Tests: Hawkins-Kennedy, Neer
Differential Diagnosis/
Pattern Recognition
• Labral Pathology/Dysfunction
– May be traumatic or can see with repetitive overhead
activities such as throwing
– Deep pain, anterior or posterior depending on location of pathology
– Catching, clicking, locking, slipping
– Special Tests: Speeds, O’Brien Active Compression Test,
Crank Test, Biceps Load II
• Biceps Pathology/Dysfunction
– Anterior shoulder pain
– Pain with behind back IR
– Pain with end-range overhead positions
Differential Diagnosis/
Pattern Recognition
• OA
– > 60 yo,
– Pain/stiffness first thing in the morning
– History of trauma, injury, or surgery
– More common at AC joint than GH joint
– Clicking/creaking/popping
– PROM and AROM limitation
• Adhesive Capsulitis
– 40-60 yo, female > male, diabetes, thyroid issues, cardiovascular
disease, recent immobilization
– ROM restriction (ER > ABD > IR)
– PROM = AROM
Differential Diagnosis/
Pattern Recognition
• Instability
– Complaints of instability/slipping/catching
– History of trauma (especially ABD/ER position)
– Hypermobility elsewhere in the body
– Special Tests: Apprehension/Relocation Test, Load & Shift
• Fracture
– History of trauma
– Unwilling to move shoulder
– Localized tenderness
• AC joint sprain
– Fall on tip of the shoulder
– Pain very localized to AC joint
– Pain with horizontal adduction
Interventions
• Dependent on suspected source of symptoms
• Postural education, exercises, and manual interventions
• Dependent on stage & irritability of the patient’s condition
• Dependent on impairments identified
– Weakness  Strengthening
– Range of Motion limitations  AROM, PROM, AAROM
– Joint hypomobility  Manual interventions
– Joint hypermobility  Stabilization
Referring the Patient to
Ortho/PCP from PT
• The patient is not appropriate for PT
– History of trauma and patient is unwilling to move UE
– Suspicion of fracture
– Presence of constant, unrelenting pain that is unchanged
(improved or worsened) with any activity
– Reproduction of pain with exertion but no reproduction
with objective examination
• The patient is not responding to PT
– If no change in symptoms within 3-4 treatment sessions,
further assessment or imaging may be warranted
– If patient’s irritability is too high and pain cannot be
managed with PT initially
Rehabilitation for
Rotator Cuff Pathology
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Patient education
Pain modulation
Postural treatments
Regain ROM
– AROM, AAROM, PROM
– Joint mobilizations
• Strengthen remaining rotator cuff
– Isometrics
– Isotonics against gravity
– Isotonics with external resistance
Rehabilitation (cont.)
• Strengthen scapular stabilizers
– Middle and lower traps
• Return to functional daily activities
• Return to functional recreational activities
Pre-hab Prior to Surgery
• Regain ROM
• Strengthen as much as possible
• Patient Education
• Patient Education
• Patient Education
thank you!
Jill Hipskind, PT, DPT, OCS, CSCS, CMT
Rock Valley Physical Therapy
jill.hipskind@rockvalleypt.com