Musculoskeletal Shoulder Pathology Chart
Pathology
Rotator Cuff
Tendinitis
Signs and Symptoms
-AROM may be reduced
-Possible painful arc
-PROM normal
-Resistive painful in
primary motion of involved
structure
-Normal mobility testing
Special Tests
-Palpate
-Resistive IR or ER
-Empty Can vs. Full
Can
-Belly Press Test
-RC special tests
may be painful but
strong
Suprispinatus
Tendinitis
-Hard to differentiate from
infraspinatus
Infraspinatus
Tendinitis
-ER may be most painful
-Can be injured in
deceleration of overhead
activities e.g. throwing,
volleyball
Subscapularis
-
-Palpate directly
anterior and
inferior to the
acromion with the
arm behind the
back
-Most prominent
posterior to
acromion when pt
is prone on elbows
with shoulders
adducted and ER
-Palpate under the
pec major with pt
supine
-Palpate biceps
Bicipital
History
-Anterolateral
shoulder pain
-Pain ↑at night
w/arm by side
or overhead
(wringing out)
-Rupture in
-AROM: may be full with
PT Interventions
-Education “wringing out”
-Control Inflammation: Ice, E-Stim,
Ionto
-Painfree ROM
-Heat, Effleurage, Exercise after
acute stage
-Mobilize stiff joints
-Stabilize hypermobile joints
-Correct FMP w/stretching,
strengthening, neuromuscular reed
-Scapular taping
-Fxn training
-Sport activity/specific
-See RC tendinitis
Other
-Most common
referral for
shoulder, may
or may not be
accurate
-See RC tendinitis
-See RC tendinitis
-Rare
-Similar to RC tendinitis
1
Tendinitis/Ten
osynovitis
Impingement
Syndrome
-1° (structure)
-2° (FMP)
-Internal
Stage1: <25yrs,
reversible
lesion, edema,
hemorrhage
Stage2: 2540yrs,
tendinitis and
fibrosis
Stage3: >40yrs,
rot cuff tears,
long head
biceps rupture
Impingement
Syndrome:
Calcific
Tendinitis
chronic cases
esp. if cortisone
injections
-As per RC
tendinitis
-Repetitive
overhead
activity in sport
or work
-Exacerbating
factors; laxity;
inflammation;
posture
-Ant. shoulder
pain (↑at
night)
-Affects ADLs,
lifestyle
painful arc in flex>abd
-PROM: full painfree
-Resistive: Pain with elbow
and shoulder flex
tendon
-Speed’s Test
(Snout)
-Yergason’s (Spin)
-Trans. friction massage
-Medical cortisone injections, antiinflammatory meds, surgical
reattachment of tendon to groove
-Tenderness anterior
acromion, AC, supra/infra,
greater tuberosity
-AROM painful arc 60°-120°
-ROM reduced in later
stage disease, abd/ER/ext
-Poor posture, protracted,
ant tilt, downward
rotation, tight pec minor
-Post. shoulder tight
-Weak/painful supra/infra;
delt; biceps
-ER weaker than IR
-Weak trapezius, serratus
-Neer’s
Impingement Sign
(SNout)
-Hawkins’-Kennedy
(SNout)
-Internal rotation
resisted strength
test (IRRS) (SNout)
(SPin)
-May have pain at any
point in the arc due to
contraction of
supraspinatus
-X-ray
-Retraction of the scapula increases
subacromial space 150-200%
-ACUTE:
-Rest
-Tendon on slack
-Reduce inflammation: Ice,
ultrasound, TENS
-Early exercise intervention
-PROM
-AAROM
-Isometrics w/o pain
-Closed chain exercises
-Co-contraction exercises
-ROM exercises w/o impingement
ranges
-Scapular Stabilization
-Strengthen below shoulder level
first
-SUBACUTE:
-Full painfree ROM
-Isotonic full ROM strengthening
-Isokinetic (cybex, biodex)
-Pt Education
-Mobilization/stretching
-Cross friction massage
-Ultrasound shown to be beneficial
for long periods
Internalposterior cuff
impinged on
posterosuperior
glenoid labrum
w/arm 90° abd
and ER (2°to
laxity)
-Pain in extreme
abd/ER
-Deposits
↑tendon size
and lead to
impingement
Combo of HawkinsKennedy,
Impingement Sign,
Painful Arc, and
Infraspinatus
muscle test yielded
best positive test
probability for any
degree of
impingement
syndrome
-Surgery
indicated if not
improved after
>6 months
2
Subacromial
Bursitis
Rotator Cuff
Tears
-Interstitial
-Partial
thickness
-Full Thickness
-Overuse or
significant
change in
overhead
activity
-May be 2° to
chronic
degenerative
lesions of rot
cuff
-Acute: Rapid
onset; usually
painful at rest
and night
-Chronic:
Gradual,
overuse, pain
limited to
deltoid region,
no sleep
interference
-Repetitive
microtrauma
-FOOSH
-Impingement
and sudden abd
movement
without ER
(debated)
-Unexpected
push/pull force
-During
shoulder
dislocation
-AROM: Acute-all motion
hurts; Chronic-painful arc
60-120° scaption
-PROM: Non-capsular
pattern w/limited elevation
-Resistive: Acuteeverything hurts; Chronicno pain
-Mobility testing: usually
negative
+Impingement
tests
-Local tenderness
-Painful arc 60°-120°
-Weakness of abd and ER
(supraspinatus)
-Abd still possible with
partial or full tears but may
be painful
-Stiffness
-Complete tear loss of abd
(and/or ER) despite deltoid
-
-Drop arm sign
(SPin)
-Ext Rot Lag Sign
(SPin, SNout)
-Int Rot Lag Sign
(SPin, SNout)
-Rent test (SPin,
SNout)
-Belly Press Test
(SPin)
-Empty can (SNout)
-Full can
-Acute- Symptoms subside 2 wks
w/adequate rest
-Chronic- Address mechanics
-
-Repair?
-Open, Mini-open, Arthroscopic
-Size, type, location of tear
-Tissue quality, fixation method
-PROM early: rot motion 1st at
45*abd, working to 90° abd, final
stage arm at side
-Early muscle training: rhythmic
dynamic stabilization better than
isometrics
-Strength progression no more
than 1lb./week
-Hard to
differentiate
from tendinitis,
bursa attached
to substance of
RC
-Full thickness
tears rare under
age 40
-Affect GH
stability
-Prognosis
depends on
history, size and
location of tear
3
-Severe acute
pain during
injury
-Night pain
-Pain or
difficulty with
overhead
activities
Degenerative
Rotator Cuff
Disease
(Thinning of
rotator cuff with
tears)
-Painful arc (60-120°)
-Reduced ROM in abd, ER,
ext, hand-behind-back
-Reversed scapulo-humeral
rhythm
-Pain and weakness on
resisted abd, flex, ER, IR
-Tenderness in palpation of
RC insertion
Total Shoulder
Replacement
-2° to
osteoarthritis,
rheumatoid, or
traumatic
arthritis
-Limitations of
ADL fxn
secondary to
-Severe loss of UE strength
-Impingement signs -Non-painful resistive or AROM
-Neer (SNout)
-Educate movement modification
-Hawkins (SNout)
-Low grade strengthening (1-5 lbs
at 40%MVIC)
-If +supra
-DON’T BE OVER AGGRESSIVE
weakness,+ER
weakness,
+impingement=
98% chance rot
cuff tear
(or 2 positives
>60yrs old)
-Palpation
-As per impingement syndrome
-Drop arm test
and RC tears
-Ext rot lag sign
-Analgesics, E-stim for pain
-Int rot lag sign
-NSAIDS, ultrasound for
inflammation
-Stretching, ROM (Wand ex, table
ex, wall ex)
-Restore appropriate mechanics
-Strengthen RC to stabilize humeral
head
-Educate about movement
modification
-In advanced cases, immobilization,
rest, surgery
-Max protection 1-3weeks
-RC repair 4-6 weeks
-Sling 2-3 weeks
-PROM, AAROM esp. flexion, abd to
90° (in neutral rot, elbow flexed),
ER @ 0° abd to neutral
-AROM elbow, wrist, hand
-Pendulum
-If severe OA
and RC disease
both present
w/pain, a
shoulder
arthroplasty
may be
indicated
-Aggressive with
motion but not
with
strengthening,
you can always
strengthen!
4
pain
Glenohumeral
Instability
-Subluxation
-Dislocation
Anterior
Shoulder
Dislocation
-Bankart lesion
-Hill-Sachs
lesion
-SLAP lesion
-HAGL lesion
-ALPSA lesion
-History of
trauma, loose
joints, “shifting,
slipping”
-Mod protection 3-6 weeks
-AAROM prog to AROM as tol
-ER w/arm in 0° abd and flex
-Wand, overhead pulley, wall
climbing ex
-Isometric exercises in varying
degrees emphasize rot cuff,
deltoid, scap muscles (arm at side)
-Min protection
-Strengthen shoulder girdle
w/progressive resistive exercise
against light resistance through
available ROM
-Closed-chain UE ex (Rhythmic
stabilization, stabilize proximal,
move distal) and wall pushups
-Gentle self stretches
-Fxn specificity of exercise
6-8 weeks to 6 mo/1year resisted
ex as tolerated
-Observe asymmetry,
winging, atrophy
-AROM may be full but
apprehensive in abd/ER
-PROM may be increased
-Resisitive: not a contractile
lesion unless RC tear
-Mobility: Increased in
direction of instability;
muscle guarding
Apprehension/relo
cation (SPin)
-Sulcus sign (SPin)
-Load and shift
(SPin)
-Closed reduction
-Immobilization in ER or not at all
-3-6 weeks (<40yrs)
-1-2 weeks (>40yrs)
-AROM elbow, wrist, hand
-Acute Phase: ex in protected ROM,
isometrics for RC, biceps
-Start dynamic rhythmic
stabilization ASAP
-When stretching permitted,
-Recurrence 6090% in ppl
<20yrs
-Jobe 4 P’s:
GH protectors,
scapular
pivoters,
humeral
positioners,
humeral
5
-Palpation: localized
tenderness over joint
Multidirection
al Instability of
Shoulder
Posterior
Dislocation/
Subluxation
-Symptomatic in
multiple
directions
-Common in
young women
w/hypermobility
, athletes
<40yrs, large RC
tears,
-Recurrent
dislocation/subl
uxation
-Often no
associated
trauma
-RC pain first presenting
symptom
-Significant ligamentous
and capsule laxity (typically
bilateral)
-Muscle imbalance/
incoordination
-
-Blow to the
front of the
shoulder
-Indirect force
applied to
humerus that
combines flex,
add, IR (FOOSH)
-Presents with
arm abd and IR
-Complains
“slipping or
shifting”
-May lose deltoid contour
-May have reversed HillSachs lesion
-May have humeral head
prominence posteriorly
-Tear of subscapularis or
lesser tuberosity avulsion
-Post shoulder pain
-Sulcus Sign (SPin)
-Load and shift
(SPin)
-Painful arc
-Positive
apprehension
-Hyperabduction
test (SPin, SNout)
+Sulcus sign in full
ER may indicate
increased rotator
interval (btwn
superior
subscapularis and
anterior
supraspinatus)
-Jerk test (SPin,
SNout)
-Kim test (SPin,
SNout)
passively stretch post joint capsule
w/mobs and self-stretching
-↑strength, regain RC control,
stability
-Patient education
-Strengthen RC and scapular
stabilizers for balance
(Isolated, Coordinated, Functional,
Return to sport)
-Reduce pain/inflammation
-Proprioceptive re-ed at GH
-DYNAMIC STABILITY
propellers
-Post-Op:
-Immobilized sling 6weeks
-Slow ex prog
Abd restricted to 90°, ER restricted
to 30° for 3-6weeks
*Post glide CONTRAINDICATED
-Refer to anterior dislocation
except avoid flexion w/add and IR
in acute phase (horiz. add)
-Immobilized 3-6weeks (<40 yrs); 23 weeks (>40 yrs)
-Strengthen posterior musculature
(infra, teres minor, post deltoid)
6
Labral Tears
SLAP Lesion
I-degenerative
but attached
II-sup labrum
detached A-P;
unstable biceps
III-sup labrum
displaced into
joint; stable
biceps
IV-bucket
handle; biceps
tendon
splitting
Acromioclavicu
lar Joint Sprain
Grade I-VI
Grade I- no
disruption of
AC joint
Grade II- Tear
w/closed chain
-History of
overuse or
trauma
-C/O deep pain
or instability,
“clicking,
popping,
catching”
I: not pathologic
II: arthroscopic
repair w/suture
anchors
III: Excision or
repair
IV: Debridement
or repair of
labrum and
biceps tendon
-Fall on tip of
shoulder or
FOOSH
-Repetitive
reaching (esp.
across chest or
overhead)
-Local pain at AC
joint or other
involved
-AROM: may have painful
click and pain in area of
lesion
-PROM: may palpate click
w/motion
-Resistive: usually negative
-Mobility testing: may have
hypermobility or functional
instability
-Palpation: deep pain,
unable to palpate
-Obrien’s Active
Compression Test
(SPin, SNout)
-Anterior Slide Test
(?)
-Biceps Load I and
II (SPin, SNout)
-Tenderness to palpation
-Localized AC pain
-“Step down” deformity
-Swelling, deformity
-AROM- painful end range
(esp. horizontal add; hand
to opp shoulder)
-PROM- pain at end range
-Resistive: III has deltoid
and trap involvement,
-AC horizontal
adduction (SPin,
SNout)
-AC resisted
extension (SPin,
SNout)
-Obrien Active
Compression Test
(SPin, SNout)
-Treat instability to get muscular
balance as in instability
-Reduce pain and inflammation
-Restore ROM
-Strengthen ST and GH to improve
dynamic stability
-Emphasize closed-chain ex
-Carefully monitor or avoid ex
stressful to biceps tendon
Post-Op:
-Initially treat inflammation
-Start low level isometrics/cocontraction
-Avoid aggressive early exercise
and ROM to avoid synovitis
-Avoid forceful stretching into
Abd/ER, forceful flexion w/post
tears, early resistance w/biceps in
SLAP.
-Educate patient to slow down
-Reduce pressure and traction AC
joint to allow ligaments to heal
-Restrict reaching and direct
pressure over shoulder
-Limit lifting 10-20 lb held close to
body
-Immobilization initially for healing
and pain control
-Ice, ultrasound, ionto, TENS,
taping
-Chronic cases
may benefit
from cortisone
injections
7
or rupture AC
ligament,
partial
displacement
Grade IIIRupture AC
and CC, strain
deltoid and
trap
Grade IV-post
dislocation of
clavicle
ligaments
-Overuse
syndromes
common among
swimmers,
volleyball,
tennis players
(Ext, Add, IR)
-Hypomobility
left over from
previous trauma
-Rarely any fxn
problems from
hypomobility
MMT painful in acute
sprains
-Mobility testing- Grade Ino laxity
Grade II/III- AC laxity
Grade V- loss
of AC/CC
ligaments, torn
deltoid/trap
attachments,
gross
deformity,
severe pain
(worst type)
Grade VIDisplacement
of clavicle
behind
coracobrachiali
s
Sternoclavicula
r Joint Injuries
-Padding and protection until
painfree ROM returns
-If hypermobile try rest, frictions,
grade II mobs for pain relief
-If hypomobile try grade III/IV mobs
-Painfree strengthening from
Isometrics to PRE’s
-Immediate ROM, isometrics
-Avoid sleeping on either side
-Full PROM by 2-3 weeks
-Grades I, II, III may require 3 weeks
immobilization for pain; full return
to activity 6-12 weeks
-Progress function and strength as
tolerated w/o pain and swelling
-Grade I/II-nonsurgical, 2wks sling
-Grade III-Controversial; surgery for
high demand workers, athletes;
conservative for chronic unless tx
fails
Grade IV/V/VI- Surgical, pins,
plates, suture, screws or removal of
distal clavicle
-Anterior force
to shoulder
-Medial end of
-Grade I: pain and slight
disability
-Grade II- pain, subluxation
-Low rate of
injury
-Post dislocation
8
Adhesive
Capsulitis
1°- idiopathic,
progressive
loss of ROM
and increased
pain
2°- Result of
soft tissue
injury,
fracture,
arthritis,
hemiplegia
Thoracic Outlet
Syndrome
clavicle can go
medially,
superiorly, and
either anterior
or posterior
-Dislocate in
adults; fracture
in children
-Indirect force;
blunt trauma
-Gradual onset
-Inability to
sleep on
affected side;
↑pain at night
-Slow
progression of
loss of ROM
accompanied by
pain
-Difficulty
combing hair,
fastening bra,
tucking in shir
-Comorbidities:
Diabetes,
thyroid
dysfunction, MI,
40-70yrs,
female 70%
with deformity, swelling,
point tenderness, and
decreased ROM
-Grade III- gross deformity,
dislocation, pain, swelling,
decreased ROM, possibly
life threatening
-Primary sites
include the
scalene triangle,
IF ANY CERVICAL ROM
REPRODUCES PAIN IT IS
NOT TOS
-PROM reduced
-AROM reduced
-Elevation limited <100°; ER
limited <45°
-Reversal of
scapulohumeral rhythm
-Restricted accessory
passive testing
Stage I (Freezing)-painful
period; 10-36 weeks
Stage II (Frozen)- stiff
period; 4-12 months
Stage III (Thawing)recovery of ROM; 5-24
months
dangerous risk
to trachea,
esophagus,
veins, etc.
-Modalities- electrotherapy,
ultrasound, heat/cold (very little
evidence but may reduce pain and
muscle spasms in order to facilitate
stretching/manual techniques)
-Stretching TERT (total end range
time) 30 min; emphasis on rotator
interval (anterior) and CHL
-Mobilization: Grades depend on
severity and irritability; pain versus
range; end range mobilizations
better outcomes; posterior glides
for ER ROM
-HEP/Education: Wand, door
pulleys, self mobs, pendulum ex,
use irritability/severity as guide
-Consider cortisone if pain>stiffness
-Consider more aggressive
intervention like manipulation
under anesthesia, surgery, if no
improvement
-Adson’s Test (SPin) -Education about deep breathing,
-Costoclavicular
relaxation techniques
maneuver (?)
-Avoid carrying heavy objects
-Surgically
associated with
synovitis
between biceps
and
subscapularis;
scarred rotator
interval
-Stage III is most
effective range
to treat patients
9
2 Types:
-Vascular
-Neurogenic
(True/Disputed
)
2 Categories:
-Compressors
-Releasors
Complex
Regional Pain
Syndrome
-Type I:
triggered by
noxious event
not associated
w/ID nerve
injury
costoclavicular
space, pectoralis
minor
-Possible
cervical rib
-Numbness/
tingling in the
ring and small
fingers or entire
hand
-Paresthesias at
night or during
daily activities
-Vague pain in
the UE
-“Arms feel
heavy”
C/O swelling in
arm in absence
of true swelling
-History of
seemingly
unrelated UE
problems
-Initiating
noxious
event/cause
immobilization
-Burning or
stinging pain
disproportionat
e to injury
-Edema,
changes in BF,
True Neurogenic- hand
weakness; muscle wasting;
cervical rib; positive EMG
for axon loss;
Disputed NeurogenicNegative imaging, negative
vascular tests
-Wright’s (?)
-Hyperabduction
(SPin for
parasthesias)
-Cyriax release test
(SPin)
-Roos (SPin, SNout)
-Positioning ad vice (arms
supported, avoid sleeping on
involved side, use orthopedic
pillow, switch sides of bed)
-Soft tissue to scalene, pec minor
-Joint mobilizations to upper
thoracic spine, posterior capsule,
1st rib
-Neurodynamic mobilization,
flossing, active, passive
-Therapeutic exercises: scalene
stretch;pec minor stretch; post
capsule stretch; chin tucks; foam
roll; scapular retraction; thoracic
extension; scapular strengthening;
serratus anterior strengthening;
neurodynamic glides
-Scapular taping for upward
rotation
-Bone scans,
thermogram,
sympathetic blocks,
X-rays, EMGs, NCV
studies, CT Scan,
MRI…etc. Non-PT
-Managed pharmacologically,
sympathetic blocks,
sympathetectomy,
neuromodulation, psychologically
-Therapy intervention to minimize
pain
-DO NOT IMMOBILIZE
-Modalities: HVGS w/gloves and
socks, contrast baths, moist heat,
fluidotherapy, TENS; try to keep
Compressors- Symptoms
w/overhead; don’t wake at
night; overhead work
occupation
ReleasorsSymptoms at night;
sedentary occupation;
large heavy arms; poor
posture (heavy chest and
breast)
-Swelling
-Stiffness
-Abnormal color or temp
-Sweating
-Trophic changes
-Muscle spasms
-Weakness/fatigue
-Functional limitations
Stage I-pain limited to site
10
-Type II:
involves direct
or complete
injury to nerve
or one of its
branches
-Type III:
doesn’t fit I/II
temperature
difference,
abnormal
sudomotor
activity in region
of pain
-Stressful social
event within 2
months before
or the month
after trauma
(divorce, death,
job loss, etc.)
of injury, localized swelling,
lasts a few weeks
Stage II-pain more severe
and diffuse, swelling
spreads, hair coarse, bone
and muscle wasting, lasts
3-6months
Stage III-atrophic tissue,
wasting, pain intractable in
entire limb, may last
lifetime
active
-Edema Control: compression
gloves, gentle STM, Jobst pump,
elevation of involved limb
-Desensitization
-Gentle AROM/PROM
-Tendon gliding ex
-Postural Education
-Mobilization of upper T-spine
-Pool Therapy
-Aerobic Ex
-Weight bearing (closed chain)
-Pt Education to avoid caffeine,
alcohol, smoking, environmental
extremes; modify activities;
vocational rehab
11