Shoulder soft tissue conditions

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