Shoulder soft tissue conditions

• Symptoms
  • Pain in the anterior and superior aspect of the shoulder
  • Pain and weakness that worsen with overhead movements, such as reaching, throwing, or lifting objects
  • Pain that may radiate down the arm
  • Pain that is worse at night
• Diagnosis
  • Clinical presentation
  • Special tests
    • Neer test - forced forward flexion with the scapula stabilized compresses the supraspinatus against the anteroinferior acromion
    • Hawkins-Kennedy test - shoulder flexed to 90 degrees with internal rotation compresses the supraspinatus under the coracoacromial ligament
    • Painful arc
      • Shoulder pain that occurs when abducting an arm between 60 and 120 degrees.
  • MRI
• Medical management
  • Surgical (subacromial) decompression if indicated
• Physical therapy intervention
  • Avoidance of shoulder elevation greater than 90 degrees to avoid subacromial compression - acute phase
  • Postural re-education - improve forward head, rounded shoulders, and kyphotic posture (upper cross syndrome)
  • Correction of muscle imbalances
  • Improve joint mobility
  • Return to previous functional status
  • Follow the post-operative protocol after subacromial decompression if indicated

Rotator cuff tear

• Acute tears are caused by a fall on an outstretched hand (FOOSH), sudden heavy lifting, or loading the shoulder in an awkward position

• Degenerative or partial tears develop over time from chronic tendonitis and poor blood supply at the tendon insertion

• Symptoms

  • Pain when raising or lowering the arm
  • Weakness when lifting or rotating the arm
  • Pain when reaching behind the back
  • Pain that worsens after lying down on the affected side
  • Pain that is worse at night

• Diagnosis

  • Clinical presentation
  • Special tests - empty can test, drop arm test, manual muscle testing of infraspinatus and supraspinatus
  • MRI

• Physical therapy intervention

  • Conservative management: scapular stabilization and graded rotator cuff strengthening in pain-free range
  • Surgical protocols if indicated, avoiding active motion that breaks protocol in the early phase after a repair
    • After a rotator cuff repair, the arm is kept in a sling with passive motion only for the first 4 to 6 weeks while the tendon heals back to bone; active exercises follow, and the PT introduces strengthening at about 8 to 12 weeks

Subacromial/subdeltoid bursitis

• Subacromial and subdeltoid bursae become inflamed (close relationship with rotator cuff tendonitis)

  • The bursa becomes trapped (impinged) beneath the acromion arch

• Symptoms

  • Pain may worsen with overhead movements, such as reaching for objects or lifting the arm.
  • The shoulder may be tender to the touch, especially around the acromion process.
  • The bursa may become inflamed and swollen, causing a visible bulge or lump in the shoulder.
  • The shoulder may feel stiff and difficult to move
  • When moving the shoulder, there may be clicking or popping sounds as the bursa rubs against the acromion bone.
  • Empty end-feel: passive movement stops because of the patient’s pain, not a physical block.

• Diagnosis:

  • Clinical examination - ruling in and out other diagnoses based on symptomatology, as well as assessment of range of motion and muscle strength

• Physical therapy intervention

  • Avoidance of provoking overhead activity in the acute phase, then postural correction and progressive strengthening

Bicipital tendonitis

• Inflammation of the long head of the biceps

  • Cases can involve mechanical impingement of the long head of the biceps under the coracoacromial arch, or irritation as it glides within the bicipital groove

• Symptoms

  • Sharp, throbbing, or dull pain in the front of the shoulder that may radiate down the upper arm - pain worsens with overhead movements, such as reaching, lifting, or throwing.
  • Localized tenderness over the biceps tendon, particularly where it passes over the shoulder joint.
  • A feeling or sound of snapping or popping in the shoulder when moving the arm.
  • Weakness in the biceps muscle, making it difficult to lift or bend the arm.

• Diagnosis

  • Clinical presentation, positive Speed’s and Yergason’s tests.
  • MRI

• Physical therapy intervention

  • Avoidance of provoking overhead activity in the acute phase, then postural correction and progressive strengthening

Adhesive capsulitis

• Restriction in shoulder motion due to inflammation of the joint capsule

  • Restrictions are in external rotation (greatest), then abduction, then internal rotation (capsular pattern of the shoulder)
  • Progresses through three stages: freezing (painful, progressively restricted motion), frozen (stiff but less painful), and thawing (gradual return of motion)
  • Risk factors include diabetes, thyroid disease, cardiovascular disease, and prolonged immobilization (for example, after injury or surgery)

• Symptoms

  • Restriction in external rotation, abduction, and internal rotation, causing functional deficits

• Diagnosis

  • Clinical presentation
  • Functional limitations

• Medical management

  • Management of diabetes, cardiovascular, or thyroid disease if applicable

• Physical therapy management

  • Improve joint mobility in the capsular pattern - gentle mobilization in the freezing stage, more aggressive stretching/mobilization in the frozen and thawing stages
  • Return to prior functional status
  • Improve muscle imbalances

Use this table to tell apart conditions that present similarly: