Shoulder soft tissue conditions | NPTE-PTA Comparing clinical presentation and interventions for upper extremity

Shoulder soft tissue conditions

Unless a condition below calls out something different, medical management typically includes acetaminophen or NSAIDs for pain and inflammation, and physical therapy interventions are chosen based on the phase of healing (acute, subacute, or chronic). The entries below focus on what’s different for each condition - special tests, surgical considerations, bracing, or splinting - rather than repeating that baseline every time.

Glenohumeral dislocations and instability
- Dislocations of the glenohumeral joint caused by traumatic or atraumatic reasons
  - Trauma is due to direct injury, most commonly a fall on an outstretched hand (FOOSH) mechanism of injury
  - Atraumatic can be due to repetitive injury, causing hypermobility
- Types of dislocations:
  - Anterior-inferior dislocations: Most common type (95%). Mechanism is a combination of motions including: excessive horizontal abduction, abduction, external (lateral) rotation, and extension/hyperextension of the upper extremity.
    - If traumatic can lead to: Disruption anterior glenohumeral/capsular ligament, subscapularis, and anterior/inferior glenoid labrum
      - Sulcus sign: a depression or groove appears between the acromion and the humeral head; this finding indicates inferior or multidirectional instability rather than being specific to anterior dislocation.
      - Hill-Sachs lesion: compression fracture of the posterior humeral head
      - Bankart lesion: avulsion of the anterior-inferior glenoid labrum
      - Axillary nerve injury: numbness, tingling, and weakness in the deltoid
  - Posterior dislocations: rare, caused by horizontal adduction and internal rotation

Symptoms
- Popping during movements
- Repeated dislocations or subluxations of the glenohumeral joint
Diagnosis
- Clinical presentation - apprehension test positive for anterior instability; sulcus sign positive for inferior instability
- Special test - apprehension test (highly specific for anterior instability)
- X-ray
Medical management
- Surgery as indicated
Physical therapy interventions
- Strengthening the capsule and muscles directly connected to prevent further dislocations
- Functional training
- Avoidance of apprehension position
- Surgical protocols if indicated
  - With anticipated return to function in 3-4 months
Labral tears
- Tear in the cartilage ring that surrounds the shoulder joint; divided into above the middle of the socket and below the middle of the socket
  - Above the middle of the socket is called a SLAP (superior labral anterior-posterior) tear; can also involve the biceps tendon
  - Below the middle of the socket is called a Bankart lesion; it can also involve an avulsion fracture of the anterior/inferior lip of the glenoid (bony Bankart)
- Labral tears are associated with traumatic injury or repetitive shoulder dislocations
Symptoms:
- Pain increased with overhead movement or behind the back
- Shoulder weakness
- Shoulder instability/dislocation
- Pain with resisted flexion of the biceps
- Tenderness over the anterior shoulder
Diagnosis
- Clinical presentation
- MRI
- Arthroscopic surgery - gold standard for diagnosis
Medical interventions
- Surgery if indicated
Physical therapy interventions
- Focus on return to function without pain
- Restoration of muscle imbalances
- Address underlying causes of labral tears
- Surgical protocols if indicated
  - With anticipated return to function in 3-4 months
Rotator cuff tendonitis
- Caused by mechanical impingement of the distal attachment of the rotator cuff, causing inflammation of the tendons
  - Increased risk for development of tendonitis due to poor vascularity at attachment sites

Impingement syndrome
- Impingement (entrapment) of the rotator cuff tendon against the acromion due to mechanical repetition
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 and pain referral location
- Clinical presentation
- Special tests
  - Hawkins-Kennedy - subacromial region
  - Neer’s superior coracoacromial region
  - Painful arc
    - Shoulder pain that occurs when abducting an arm between 70 and 120 degrees.
  - MRI
Medical management
- Surgery 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
- Surgical decompression if indicated
Rotator cuff tear/damage
- Causes acute tear from a fall on an outstretched hand (FOOSH), sudden heavy lifting, or the shoulder in an awkward position
- Partial and degenerative damage from an increased risk for the development of tendonitis due to poor vascularity at attachment sites
Symptoms
- Pain when raising or lowering the arm
- Pain when reaching behind your 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
Medical management
- Surgery if indicated
Physical therapy intervention
- Surgical protocols if indicated
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 joints’ passive movement stops due to the patient’s pain, not because of a physical blockage
Diagnosis:
- Clinical examination - ruling in and out other diagnoses based on symptomatology, as well as assessment of range of motion and muscle strength
Bicipital tendonitis
- Inflammation of the long head of the biceps
  - Cases can be mechanical trapping (impingement) of the long head of the biceps between the acromion and the bicipital groove of the humerus
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
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)
  - Reason for diagnosis can be repetitive motion, diabetes, cardiovascular disease, or thyroid disease
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
- Return to prior functional status
- Improve muscle imbalances

Glenohumeral dislocations and instability

Anterior-inferior dislocation most common (95%); mechanism: abduction, external rotation, extension/horizontal abduction (often FOOSH)
Key associated lesions: Hill-Sachs (posterior humeral head compression fracture), Bankart (anterior-inferior labral avulsion), axillary nerve injury (deltoid numbness/weakness)
Sulcus sign = inferior/multidirectional instability (not anterior-specific); apprehension test highly specific for anterior instability
Posterior dislocations rare, caused by adduction + internal rotation
PT focus: capsule/muscle strengthening, avoid apprehension position; surgical return to function ~3-4 months

Labral tears

SLAP tear = above socket midline (may involve biceps tendon); Bankart lesion = below midline (may include bony avulsion)
Linked to trauma or repetitive dislocations
Symptoms: overhead/behind-back pain, instability, resisted biceps flexion pain
Diagnosis: MRI, arthroscopy (gold standard)
PT: address muscle imbalances and underlying cause; surgical recovery ~3-4 months

Rotator cuff tendonitis

Caused by mechanical impingement + poor tendon vascularity at attachment sites
Related to impingement syndrome (tendon entrapment against acromion)

Impingement syndrome

Symptoms: anterior/superior shoulder pain, worse with overhead activity and at night
Special tests: Hawkins-Kennedy (subacromial), Neer’s (coracoacromial), painful arc (70-120° abduction)
PT: avoid elevation >90° in acute phase, correct posture (upper cross syndrome), restore mobility/imbalances

Rotator cuff tear/damage

Causes: FOOSH, heavy lifting, awkward positioning, or degenerative/poor vascularity
Symptoms: pain raising/lowering arm, behind back, worse lying on affected side/at night
Special tests: empty can test, drop arm test, MMT of supraspinatus/infraspinatus; MRI confirms

Subacromial/subdeltoid bursitis

Bursa impinged beneath acromion arch; closely related to rotator cuff tendonitis
Symptoms: pain with overhead reach, tenderness/swelling near acromion, clicking/popping, empty end-feel (pain-limited, not mechanical block)
Diagnosis: clinical exam, ROM/strength assessment to rule out other causes

Bicipital tendonitis

Inflammation of long head of biceps from impingement in bicipital groove
Symptoms: anterior shoulder pain radiating down arm, tenderness over tendon, snapping/popping, biceps weakness
Diagnosis: positive Speed’s and Yergason’s tests; MRI

Adhesive capsulitis

Joint capsule inflammation causing capsular pattern restriction: external rotation (greatest) > abduction > internal rotation
Associated with diabetes, cardiovascular disease, thyroid disease, or repetitive motion
Medical management: treat underlying systemic disease if present
PT: restore capsular mobility, correct muscle imbalances, return to function

Shoulder soft tissue conditions

Glenohumeral dislocations and instability
- Dislocations of the glenohumeral joint caused by traumatic or atraumatic reasons
  - Trauma is due to direct injury, most commonly a fall on an outstretched hand (FOOSH) mechanism of injury
  - Atraumatic can be due to repetitive injury, causing hypermobility
- Types of dislocations:
  - Anterior-inferior dislocations: Most common type (95%). Mechanism is a combination of motions including: excessive horizontal abduction, abduction, external (lateral) rotation, and extension/hyperextension of the upper extremity.
    - If traumatic can lead to: Disruption anterior glenohumeral/capsular ligament, subscapularis, and anterior/inferior glenoid labrum
      - Sulcus sign: a depression or groove appears between the acromion and the humeral head; this finding indicates inferior or multidirectional instability rather than being specific to anterior dislocation.
      - Hill-Sachs lesion: compression fracture of the posterior humeral head
      - Bankart lesion: avulsion of the anterior-inferior glenoid labrum
      - Axillary nerve injury: numbness, tingling, and weakness in the deltoid
  - Posterior dislocations: rare, caused by horizontal adduction and internal rotation

Symptoms
- Popping during movements
- Repeated dislocations or subluxations of the glenohumeral joint
Diagnosis
- Clinical presentation - apprehension test positive for anterior instability; sulcus sign positive for inferior instability
- Special test - apprehension test (highly specific for anterior instability)
- X-ray
Medical management
- Surgery as indicated
Physical therapy interventions
- Strengthening the capsule and muscles directly connected to prevent further dislocations
- Functional training
- Avoidance of apprehension position
- Surgical protocols if indicated
  - With anticipated return to function in 3-4 months
Labral tears
- Tear in the cartilage ring that surrounds the shoulder joint; divided into above the middle of the socket and below the middle of the socket
  - Above the middle of the socket is called a SLAP (superior labral anterior-posterior) tear; can also involve the biceps tendon
  - Below the middle of the socket is called a Bankart lesion; it can also involve an avulsion fracture of the anterior/inferior lip of the glenoid (bony Bankart)
- Labral tears are associated with traumatic injury or repetitive shoulder dislocations
Symptoms:
- Pain increased with overhead movement or behind the back
- Shoulder weakness
- Shoulder instability/dislocation
- Pain with resisted flexion of the biceps
- Tenderness over the anterior shoulder
Diagnosis
- Clinical presentation
- MRI
- Arthroscopic surgery - gold standard for diagnosis
Medical interventions
- Surgery if indicated
Physical therapy interventions
- Focus on return to function without pain
- Restoration of muscle imbalances
- Address underlying causes of labral tears
- Surgical protocols if indicated
  - With anticipated return to function in 3-4 months
Rotator cuff tendonitis
- Caused by mechanical impingement of the distal attachment of the rotator cuff, causing inflammation of the tendons
  - Increased risk for development of tendonitis due to poor vascularity at attachment sites

Impingement syndrome
- Impingement (entrapment) of the rotator cuff tendon against the acromion due to mechanical repetition
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 and pain referral location
- Clinical presentation
- Special tests
  - Hawkins-Kennedy - subacromial region
  - Neer’s superior coracoacromial region
  - Painful arc
    - Shoulder pain that occurs when abducting an arm between 70 and 120 degrees.
  - MRI
Medical management
- Surgery 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
- Surgical decompression if indicated
Rotator cuff tear/damage
- Causes acute tear from a fall on an outstretched hand (FOOSH), sudden heavy lifting, or the shoulder in an awkward position
- Partial and degenerative damage from an increased risk for the development of tendonitis due to poor vascularity at attachment sites
Symptoms
- Pain when raising or lowering the arm
- Pain when reaching behind your 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
Medical management
- Surgery if indicated
Physical therapy intervention
- Surgical protocols if indicated
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 joints’ passive movement stops due to the patient’s pain, not because of a physical blockage
Diagnosis:
- Clinical examination - ruling in and out other diagnoses based on symptomatology, as well as assessment of range of motion and muscle strength
Bicipital tendonitis
- Inflammation of the long head of the biceps
  - Cases can be mechanical trapping (impingement) of the long head of the biceps between the acromion and the bicipital groove of the humerus
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
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)
  - Reason for diagnosis can be repetitive motion, diabetes, cardiovascular disease, or thyroid disease
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
- Return to prior functional status
- Improve muscle imbalances