Shoulder Pain
Stuart Williams, D.O.
Associate Professor
Osteopathic Manipulative Medicine
Evaluation of Shoulder
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Glenohumeral Joint
Acromioclavicular Joint
Sternoclavicular Joint
T1-T4
Ribs 1-4
Upper Extremity Motion Test
Patient abducts arms and extends pronated hands
over head
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Negative Test
Upper arms should touch ears
 Elbows straight.
 Forearms pronated.
 Back hands approximate equally.
 Joints of shoulder, elbow, radioulnar, and wrist are
normal.
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Positive Test
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Patient unable to bring forearms to ears, straighten
elbows, or approximate back of wrists.
 Check shoulders, elbows, and wrists.
 Also check upper ribs and upper T-Spine.
Upper Extremity Motion Test
Rotator Cuff Muscles
SITS
Supraspinatus-abduction
Infraspinatus-ext.rotation
Teres Minor-ext. rotation
Subscapularis-int. rotation
Special Tests
Apley Scratch Test and Shoulder ROM
External
Rotation &
ABduction
Internal Rotation
& ADduction
Internal
Rotation &
ADduction
Shoulder Range of Motion
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Glenohumeral and
Scapulothoracic Joint
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ABduction
ADduction
Flexion
Extension
Internal Rotation
External Rotation
180º
30-45º
90º
45-50º
55º
40-45º
Special Tests
Rotator Cuff Pathology
Arm drop Test (Empty Can Test)
Adhesive Capsulitis
“frozen shoulder”
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Gradual loss of
function
Decreased ROM Active and Passive
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External Rotation
Internal Rotation
ABduction
Diffuse tenderness
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Inflammation
Fibrous changes in
periarticular soft
tissue
Decreased joint
volume - confirmed
by arthography
Seven Stages of Spencer
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Excellent way to examine shoulder
while treating
Seven Stages of Spencer
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1.
2.
3.
4.
5.
6.
7.
Extension
Flexion
Circumduction with Compression
Circumduction with Traction
Abduction
Internal Rotation
Joint Pump
Technique (Muscle Energy)
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Contact usually over elbow, but you are
moving humerus to muscular barrier
Patient instructed to move in opposite
direction isometrically
D.O. offers counterforce (isometric)
Patient & D.O. stop. Wait for tissue to relax
(2-3 sec)
Carefully take up slack to next barrier
Repeat until best motion (usually 3 times)
Stage 1 - Extension
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Cup cephalad hand over clavicle and
scapula
Flex elbow and carry humerus into
extension to restrictive barrier
Apply muscle energy activation (patient
flexes against you while D.O. offers
counterforce) On relaxation, carry
humerus to further extension
Stage 2 - Flexion
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Caudad hand stabilizes clavicle and scapula
Flex humerus to restrictive barrier should
have 180° arc motion
Apply M.E. to active (patient attempts to
extend shoulder against counterforce)
Relaxation (wait 2-3 seconds)
Carry shoulder in flexion to new barrier
Repeat 2-3 times as needed
Stage 3 – Circumduction
with Compression
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Cephalad hand cups clavicle and scapula to
stabilize
Flex elbow and abduct humerus to 90°
Compress gently to seat head of humerus in
glenoid fossa
Circumduct elbow clockwise and counterclockwise in a cone shape
Any areas of resistance-modify elbow
pressure and change circumference of cone
Stage 4 – Circumduction
with Traction
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Cephalad hand cups clavicle and
scapula to stabilize
Grasp wrist and apply traction
Circumduct arm in cone-like fashion
both clockwise and counter-clockwise
Any areas of resistance, modify the arm
traction and/or change circumference of
the cone
Stage 5 - Abduction
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Cephalad hand continues to cup clavicle
and scapula to stabilize
Patient flexed at elbow
Adduct humerus to restrictive barrier
Apply muscle energy activation (patient
adducts against D.O.)
On relaxation (wait 2-3 seconds), carry
to new barrier
Stage 6 – Internal Rotation
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Cephalad hand cups clavicle and scapula
Place patient’s hand behind L/S area
Internally rotate humerus by moving elbow
anteriorly
Active muscle energy (patient externally
rotates against resistance)
Have patient relax. Wait 2-3 seconds.
Internally rotate to new barrier
Stage 7 – Joint Pump
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Extend patient’s elbow
Abduct patient’s humerus
Place patient’s hand on your shoulder
Place your hands and fingers over
humeral head
Apply caudal force with a scooping
pumping action
Seven Stages of Spencer
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1.
2.
3.
4.
5.
6.
7.
Extension
Flexion
Circumduction with Compression
Circumduction with Traction
Abduction
Internal Rotation
Joint Pump