Physiotherapy Care Protocol for Shoulder Pain Update May

KEMENTERIAN KESIHATAN MALAYSIA

PHYSIOTHERAPY

CARE PROTOCOL

FOR SHOULDER PAIN

Physiotherapy Care Protocol

P H Y S I O T H E R A P Y

TECHNICAL COMMITTEE PHYSIOTHERAPY

PROFESSION MINISTRY OF HEALTH

MALAYSIA 2011

PHYSIOTHERAPY CARE PROTOCOL FOR SHOULDER PAIN

Working Committee, Physiotherapy Profession MOH February 2011 1

CONTENTS

1

Definition

2

2

Overview

2

3

Signs and symptoms

3

4

Causes of shoulder pain

3

5

Investigation (Doctor)

4

6

Diagnostic Triage

4

7

Differential Diagnosis

5

8

Assessment

8

9

Goals of Treatment

9

10

Intervention

14

11

Discharge care plan

18

12

Supplementary notes

19

13

Algorithm

21

14

References

22

15

16.

Glossary

Appendix Headings

24

26

17.

Appendix A

27

18.

Appendix B

30

19.

Appendix C

35

20.

Appendix D

37

21.

Appendix E

39

22.

Appendix F

45

23.

Appendix G

46

24.

Appendix H

48

25.

Appendix I

49

26

Editors

52

27

Contributors

53



1. DEFINITION

Pain in the shoulder region can arise from the glenohumeral (GH) or acromioclavicular (AC) joint, or from the periarticular structures or it may be referred from the neck, thoracic or abdomen (Woodward TW & Best TM, 2000). The term acute is defined as pain that is present for less than 3 months; it does not refer

to the severity or quality of pain.

Chronic pain is pain that has persisted for more than 3 months (Mersky & Bogduk, 1994).

2. OVERVIEW

In government hospitals in Malaysia, shoulder pain is the second most common

musculoskeletal problem seen as outpatients in the physiotherapy departments.

(Statistics collected from physiotherapy departments, MOH Malaysia). As reported by Cailliet, 1981, pain in the shoulder is the third most commonly experienced in

musculoskeletal pain. Shoulder pain is a common reason for seeking treatments as it

affects activities of daily living including sleep (van der Heijden 1999).

Many people with acute shoulder pain are likely to recover fully without treatment. It is

evidenced that 23% of all new episode of shoulder pain resolve fully within 1 month and

44% resolve within 3 months of onset (Van Der Windt et. al, 1996).

There is a risk that uncomplicated shoulder pain may persist beyond the acute phase

due to poor posture, coping styles and occupational factors (Van Der Heijden, 1999). Early intervention is important to prevent progression to chronic stage.



3. SIGNS AND SYMPTOMS

Pain common symptom for all shoulder problems

Restricted movement

Swelling and warmth

Muscle spasm

Weak / inhibited muscles

Tight muscles

Stiffness

Looseness - Shoulder instability

Deformity of shoulder e.g. loss of contour, winging of scapula.

Crepitus popping / clicking could be due to cartilage or rotator cuff tear or

instability of shoulder

4. CAUSES OF SHOULDER PAIN (Refer to Appendix A) The most common disorders seen are :

1. Periarticular condition, especially Rotator Cuff lesion (tendinitis, cuff tear or subacromial bursitis, impingement syndrome),

2. Soft tissue injuries affecting the shoulder girdle, 3. Shoulder instability (including labral damage and acromioclavicular (AC)

separation and Pectoral girdle nerve syndrome.

5. INVESTIGATION BY DOCTOR

Some of the investigations carried out are

X-ray

Arthrogram

MRI

Arthroscopy



6. DIAGNOSTIC TRIAGE

Classification Cause of shoulder

pain

Findings consistent with diagnosis

X-Ray finding Findings inconsistent

with diagnosis

Impingement

Rotator cuff disorder

Age usually over 40 years old, cuff weakness, atrophy, tenderness, painful arc of motion, night pain, impingement sign, upper arm pain, and crepitus.

Acromial Spur, greater tuberosity sclerosis and cysts, loss of acromio-humeral interval (X-ray may be normal)

Age below 30 years old, no upper arm pain, no weakness, no impingement sign

Overused

Arthritis of gleno-humeral joint

Age usually below 60 years, progressive pain, tender gleno humeral joint posteriorly, crepitus, decreased ROM

Humeral osteophytes, humeral head flattening, irregular or narrowed joint spaces, bone cysts

Normal ROM, normal x-ray

Restricted shoulder

Frozen shoulder / Adhesive capsulitis

Spontaneous onset of pain and stiffness which is progressive, loss of active and passive ROM in all planes - loss of internal rotation is an early sign of motion loss, no local tenderness, pain - at end range and even at rest

Non- specific (osteopenia may be present)

Normal ROM of shoulder

Instability

Gleno-humeral instability

Age usually below 40 years old, history of dislocation or subluxation, apprehensions sign, non-traumatic generalised ligamentous laxity, repetitive stress (external rotation in abduction and elevation), Sulcus Sign may be possible.

Hill-sachs deformity, anterior inferior glenoid calcification (X-Ray may be normal).

No history of dislocation or subluxation, no apprehension sign (in traumatic cause), no impingement (in non traumatic).

Reference: American Academy of Orthopedic Vurgeonia, Department of Research and scientific affairs, shoulder pain phase 1, version 2.0-2001.



Red Flag:

Age below 20 years old and above 60 years old.

Persistent pain and sleep disturbance.

Systemic signs and symptoms.

Swollen shoulder joint (non traumatic).

Caution (refer back to medical officer)

7. DIFFERENTIAL DIAGNOSIS IN SHOULDER PATHOGENESIS

MUSCLE:

History:

Unaccustomed activity

Repetitive eccentric activity

Direct, blunt trauma to muscle

Physical Examination:

Pain with contraction of involved muscle

Muscle imbalances of length and strength

Tenderness with palpation over involved muscle belly or trigger

points

TENDON:

History:

Blunt trauma to tendon area

Recent repetitive activity


Pain with end range and repetitive contractions

Weakness with moderate major pathology Associated biomechanical and ergonomic deficiencies



BURSA:

History

Recent unaccustomed overuse

Recent unaccustomed weight bearing pressure

Pain with all motions


Symptoms reproduction with palpation

Pain with both AROM and PROM

CAPSULE:

History

Pain with movement worse in one particular direction


Pain at end ROM

ROM limitation in pattern characteristic to the particular joint

LIGAMENT:

History:

Trauma

If acute swelling, pain with movement that puts strain on partial

tear

If complete tear instability and giving away

Postural strain pain with prolonged static postures eases with

change in position or movement


If acute sprain swelling, compensatory muscle spasm

If partial tear pain with ligamentous integrity test

If complete tear laxity with ligamentous integrity test



If postural strain pain with prolonged overpressure in direction of

strain, pain eases with release of pressure or movement in

opposite direction

NERVE ENTRAPEMENT

History:

Paresthesias,

narrow band of sharp pain

Cord like pulling sensation


Postural adoption to reduce entrapment

Symptoms reproduced with neural tension

Possible sensory loss

DURAL STRUCTURES:

History:

Paraesthesias with prolonged sitting or flexed positions

Diffuse multiple areas of symptoms with headaches

Autonomic system symptoms


Reproduction of symptoms with slump

Associated changes in the cervical spine

HARD TISSUES: - BONE

History:

Significant history of trauma

Pain in location unusual for a soft tissue sprain or strain


Bony deformity if displaced



Grating sensations with movement

Point tenderness over fracture site

Must be counter checked with x-ray

ARTICULAR CARTILAGE:

History:

Gradual onset of pain and stiffness

Progressive decline in function


Pain with end range stress to joint (mild cases) Pain with mid-range (severe cases) Strength and muscle imbalance deficits

Biomechanical abnormalities

8. ASSESSMENT

Detailed assessment should be carried out and documented in: Physio/AX.9/2000 form

(Peripheral Joint Assessment Form)

8.1 Subjective - Identify the onset of the complaints, taking details of:

Is the shoulder pain a result of activities, traumatic events or chronic

repetitive overuse

Identify which category of shoulder pain the patients falls into e.g.

adhesive capsulitis.

The development and course of the complaints

- Evaluate the course of the condition over time, taking details of the present:

severity and nature of complaints (impairments, disabilities and participation problems)



- Previous diagnostic procedures and treatment interventions and their results

- Note additional information on co-morbid conditions

- Current treatment: medication, other treatment or advice, and medical aids

- Work-related factors that affects patients complaint.

- Pain

Intensity of pain using visual analog scale (VAS)

Localised/ radiating

Nature eg.

Dull aching (muscle) Sharp pain & shooting (nerve) Numbness/ paraesthesia (nerve) Deep nagging, dull (bone) Sharp, severe, intolerable (fracture) Throbbing, diffuse (vascular)

Area of pain, note in the body chart

Aggravating factor

Movements/activities that increase pain

Easing factor

What patient does to reduce the pain

24 hours behaviors

Mechanical * - pain towards evening or some time after activity

Inflammatory * - night pain, pain on waking up in morning

Irritability ( Low / Medium / High )



8.2 Objective General observation

It is important to observe the shoulder complex first and then proceed to

observing the other key skeletal platforms (foot, pelvis, scapula, thoracic, upper cervical spine/AO and system of linkages) of the body. Shoulder pain is also known to be the result of form/force issues of the pelvic girdle. (Diane Lee, 2004). Refer to supplementary notes.

Shoulder complex :

Contour of shoulder girdle

Position of scapulae

Position of arm

Muscle development / wasting

Alteration in skin colour / sweating etc

Physiological movement (Active, passive, overpressure)

Range of movement

Quality of movement

Reproduction of symptoms

Scapulae-humeral rhythm

End-feel

Asymmetry compared to other side



N.B. Isolated atrophy of:

Supraspinatus and Infraspinatus Fossa- possible rotator cuff lesion,

entrapment or injury to the suprascapular nerve, disuse)

Deltoid or Teres Minor - possible axillary nerve injury

Winging of scapular - possible long thoracic nerve injury

Popeye bulge of biceps worsened with flexion of elbow (evidence of proximal tear of long head of biceps)

Deformity of AC joint grade 2 or 3 ( AC joint separation )

Passive Accessory movement

Anterior-posterior Glide

Posterior anterior glide

Inferior Glide

Lateral Glide

Stability Test

Anterior Drawer

Posterior Drawer

Apprehension Test

Below is further assessment that is required to be done in order for the

practitioner to get a bigger picture of the problem.

Static and dynamic situation / posture:

Standing posture

Foot Mechanics

Pelvic alignment



Gait

Lumbo / Pelvic Rhythm

Scapulo / Thoracic Rhythm

Thoracic Rotation

Cervical Rhythm

8.3 Palpation

Start from cervical, sternoclavicular (SC) joint and proximal clavicle and over entire shoulder complex:

- Temperature

- Muscle spasm

- Soft tissue thickening, tightness, swelling

- Tenderness (anterior shoulder tenderness is a common and non specific finding) - Bony anomalies / Prominence

8.4 Neuromuscular Examination

- Muscle Power

- Sensory

- Reflexes

- ULTT as a screening test to exclude cervical involvement.(Refer Appendix B)

8.5 Special Tests

Below are the special tests recommended to be performed to identify the structures

which could be contributing to the symptoms. This will enable the practitioner to confirm

the findings of the initial assessment.

For further understanding of the special tests please refer to appendix B.

Take note : only relevant special test should be performed based on your subjective and objective assessment.



Bil Special tests Structure to be tested Outcome / response

1. Supraspinatus test Supraspinatus muscle - Pain and weakness

2. Drop arm test Rotator cuff muscle - Unable to sustain

position

- Pain

3. Speeds test Long head of bicep - Pain in the bicipital

groove and weakness of

muscle

- Tenderness in the

bicipital groove

4. Hawkins impingement test Impingement of rotator

cuff at acromio arch

- Pain at subacromial

space

- Express apprehension

5 Passive cross- chest adduction test Acromion clavicular joint Subarachnoid bursitis

- Pain at acromion

- clavicular joint

6. Posterior Apprehension Test Humeral head - Pain

- Instability

7. Anterior Drawer Test Anterior Capsule

Anterior Glenohumeral

joint

- Instability and pain


8. Posterior Drawer Test Posterior capsule - Instability and pain


9. Upper Limb Tension Test 1

(Median Nerve Bias) Median Nerve Bias Pain and numbness

(Dermatomal pattern) 10 Upper Limb Tension Test 2B Radial Nerve basis Pain and numbness

(Dermatomal pattern) 11 Upper Limb Tension Test 3 Ulnar Nerve Basis Pain and numbness

(dermatomal pattern)



8.6 Level of impairment and Disability (Functional Disability) Using DASH DISABILITY / SYMPTOM SCORE - Appendix I

9. GOALS OF TREATMENT

Plan and prioritise intervention according to assessment and patients condition.

Goal must be related to function, be measureable and set against a reasonable

time frame.

i. Educate patient / create awareness of his condition.

ii. Decrease pain and inflammation

iii. Restore Range of motion

iv. Increase Strength

v. Restore Proprioception

vi. Restore Neuromuscular control and functions

vii. To increase patients confidence to cope adequately / Return to work

viii. Give guidance on gradual return to normal activities / Return to work.

10. INTERVENTION

( i ) Acute pain Rest sling /aids (48 to 72 hours ) if necessary

Electrotherapy modalities - Ice therapy , Tens , Inferential therapy (IT)

Therapeutic Exercise ( to be done within limits of pain ) - Isometric exercises

- Assisted active/ auto assisted.

- Passive movement if indicated

- Passive stretching

- Pendular / Codmans exercise

Advice e.g avoid activities that aggravate the pain and modify working activities

Deep breathing exercise / Breathing retraining



10. INTERVENTION

( ii ) Sub Acute Pain As pain reduces, close chain exercises must be done to facilitate coordination of both

agonist and antagonist muscle work.

Strengthening of scapula stabilizers is very important in early rehabilitation starting with

close chain exercises and advancing to open chain active free to open chain with weight

exercise.

Muscles to be strengthened are supraspinatus, infraspinatus, subscapularis, teres minor,

trapezius (upper, middle, inferior), deltoid, rhomboid and serratus anterior. Proprioceptive exercises are to be included in the regime of exercise.

Emphasis is on gradual return to functional activities according to patients needs,

especially encourage activities above shoulder level e.g reaching object. As recovery continues and more motion is gained more aggressive open chain

strengthening exercise can be included.

N.B Scapula plane position (scaption) applied in all exercises involving shoulder mobility and functional activity.

i. 30 45 deg forward to frontal plane..

ii. Arc of motion more in line with the glenoid fossa of scapula.( centres humeral head in the glenoid fossa centration )

iii. Minimal stress on joint capsule. Iv. Most functional activity occurs in this position

( iii ) Posture Training Advice patient on good posture. Avoid slouched posture while in sitting or standing. A

slouched posture reduces the subacromion space and may induce a soft tissue

impingement (Solem-Bertoft E, Thoumas KA, Westerberg C-E, 1993)



10. INTERVENTION

( iv ) Hydrotherapy Hydrotherapy may be defined as the use of water, in any of its forms, to relax, assist

/resist movement and to strengthen muscles.

The techniques that can be used are:

- Bad Ragaz

- Hallawick technique

- Ai Chi

- Proprioceptive Neuromuscular Facilitation (PNF)

( v ) Myofacial Release (MFR) Fascia tightens with inflammation of soft tissue and heals slowly ( because of a poor blood supply), and is a pain focus ( because of its overabundant nerve supply).Myofascial release (MFR), a hand-on technique that applies prolonged light pressure with specific directions into the fascia system, may be used as an adjunct to almost any treatment prescribed for the patient.

(Further reading is needed for more information.)

( vi ) Muscle energy techniques (MET) Use of various techniques to:

lengthen a shortened, contractured or spastic muscle

strengthen a physiologically weakened muscle or group of muscles

reduce localized edema,

relieve passive congestion, and

mobilize an articulation with restricted mobility.



10.1 INTERVENTION

The following are recommended interventions for the respective shoulder

conditions :

Frozen Shoulder

- Joint Mobilisation eg Gleno humeral joint - Thoracoscapular articulation mobilization

- Myofacial Release (MFR) - Muscle Energy Technique (MET)

Impingement syndrome

- Control of swelling and inflammation during acute stage

- Scapular Stabilization Exercises

- Posture Correction Exercise

- Correction of faulty component of movements eg. Abduction of arm with

internal rotation

Acute Shoulder Dislocation / Suspected Rotator Cuff tear / Labrum tear

- Reduce pain

- Control inflammation

- Restore scapula mobility and stability

- Maintain ROM to uninjured joints. - Strengthening exercise begin with close kinetic chain exercise and then

progress accordingly to open chain kinetic exercise

Uni / Multi Directional Instabilities.

- Dynamic Scapula Stabilization Exercise - Refer Appendix E

N.B. Core Stabilization Exercise ( refer to Appendix G) These are a set of exercises which may be applicable to all the above shoulder

conditions



10.2 RE EVALUATION

Re assess patient for progress:

(i) If patients symptoms improve, progress with rehabilitation programme. (ii) A discharge care plan has to be formulated before discharging the patient. (iii) If patient condition is not showing sign of improvement, change intervention / approach of treatment or refer back to doctor.

11. DISCHARGE CARE PLAN

( i ) Criteria for discharge a) DASH (Disability Assessments Shoulder Hand),

Score 30 and below (Minimal Disability) b) Visual Analog Pain Scale (VAS) . VAS score of 2 or less c) Pain free Joint Range Of Motion (ROM) (Bailey TR, et. al 2000)

o No impingement symptom

o Joint flexibility to within functional / normal limit

( ii ) Home programme a) Patient education - Refer to Appendix H

b) Exercises To perform exercises as instructed c) Discharge care plan ready to be given to patient before discharge



12 SUPPLEMENTARY NOTES

THE FOLLOWING EXPLAINS THE ROLE OF PELVIC GIRDLE IN MANAGEMENT OF

SHOULDER PAIN

The body is a series of skeletal platform and linkages supported by muscles and

controlled by the nervous system. Movement of the shoulder is not an isolated event;

rather it is just one component of many events that happen throughout the musculoskeletal system as motion flows along the kinetic chain. Evidence suggests just prior to the initiation of movement, a number of deep muscles activate and produce force

closure to stabilize craniocervical junction, along with the pelvic and lumbar spine. The pelvis is the key in most musculoskeletal dysfunctions. It is the main link in chains

(anterior and posterior oblique chains muscle) and important aspect of stability and force transmission.

A majority of musculoskeletal dysfunction is the result of cummulative micro trauma caused by impairments in alignment, in stabilization and in movement patterns of the

skeletal system.

Movement is based on an interaction of structure and function. Integrated model of

optimal kinesiologic function (Lee and Vleeming 2002) requires all the below components :

Form closure: which comprises of bone, joint and ligaments.

Force closure: refers to optimal muscle function. ( global and local )

Motor control : refers to coordinated muscle activity.

Emotional and awareness

Force closure consists of the following muscles which preset (local system) before shoulder movement take place: Transversus Abdominus, Multifidus, Pelvic Floor,

Diaphram, Deep Neck Flexors, Subscapularis, and Upper Trapezius. These key muscles

activate to SET and STABILIZE the skeleton 30 60 milliseconds before movement.

This stabilization is referred to as FORCE CLOSURE. Insufficiency in this system leads

to shoulder pain syndrome.



A number of tests have been deviced to test the stabilization of form and force closure at

the sacroiliac joint. The following are the tests: Standing Hip Flexion (Stork / Gilllets), Active Straight Leg Raise Test, and Prone Hip Extension Test. Impairment / dysfunction detected in the pelvic girdle should be addressed for optimal

outcome in the management of shoulder pain syndrome.

SACROILIAC JOINT STABILIZATION TEST

Bil Special test Structure to be tested Outcome / response

1. Standing Hip Flexion Test Sacroiliac Joint / pelvis girdle - Movement of ilium in relation

to sacrum /vice versa

- PSIS move downward and

medially on the side of hip

flexion

- Hypomobility of sacroiliac joint - No movement or superior

movement of sacrum relative to

PSIS

2. Prone Lying Hip

Extension Test

Sacroiliac joint stabilization Muscle activation sequence

(posterior oblique)

- Overactivation of latissimus

dorsi

- Initiation of movement at the

shoulder girdle muscles

3. Active Straight Leg raise Lumbo-pelvic stabilizers

Activation of local and global

muscle system

- No movement in the

lumbopelvic complex

- No deviation of the navel

- Effort difference between the

left and right leg

For further information please refer to book The Pelvic Girdle by Diane Lee, 3rd Edition, 2004,

Neuromusculoskeletal Examination and Assessment by Nicole J Petty and Ann P Moore, 3rd

Edition, 2006



13. ALGORITHM

MANAGEMENT OF SHOULDER PAIN

Referral

Assessment of Shoulder

Table of red flags: Tumours

Infection Acute trauma

Fracture and dislocation Referred pain ( from spine, chest, abdomen)

Refer to Doctor

Diagnostic Triage 1. Acute pain/ acute

shoulder dislocation 2. Impingement 3. Frozen Shoulder 4. Instabilities

Discharge Care Plan

No

Any Red Flag?

Yes

PT Intervention

No

Yes

Discharge

Re-evaluation

Any Improvement?



14. REFERENCES

1. Allegrucci M, Whitney SL, Irrgang JJ. 1994; Clinical implication of secondary impingement of the shoulder in freestyle swimmers. J Orthop Sports Phys Ther; 20 : 307-318

2. Andrews JR, Wilk KE. The athelete shoulder New York, NY: Churchill Livingstone inc; 1994

3. Brotzman SB, Wilk KE, 2003, Clinical Orthopeadic Rehabilitation, 2nd Ed.; Mosby, Pennsylvania, Shoulder Injuries, pg. 125-248

4. Brox JI,2003; Shoulder pain; Best Practice and Research Clinical Rheumatology, Vol 17, Issue 1, 33-56

5. Bullock MP et al, 2005; Shoulder Impingement: the effect of sitting posture on shoulder pain and range of motion.Manual Therapy, Vol 10, Issue 1, pg 28-37

6. Davies GJ, Ellenbecker TS. 1993; Total arm strength rehabilitation for shoulder and elbow overuse syndrome; Orthopedic Physical Therapy Home Study Course. La Crose Wis: orthopedic Section of the American Physical Therapy Assoc;

7. Davies GJ, Fortun C, romeyn R, Giangarra C, 1997; Computerised isokinetic testing of patients with rotator cuff ( RTC ) impingement syndromes demonstrate specific RTC external rotators power deficits. Abstract. Phys. Ther.; 77 : S 105.

8. DePalma MJ,Johnson EW,2003, Detecting and Treating Shoulder Impingement Syndrome; The Physcian and Sports Medicine, Vol 31, No. 7

9. Ginn KA, Cohen ML, 2004; Conservative treatment for shoulder pain: prognostic indicators of outcome; Archies of Physical Medicine and Rehabilitation. Vol 85, Issue 8, 1231-1235

10. Green S, Buchbinder R, Hetrick S, 2005. Physiotherapy interventions for shoulder pain (Cochrane Review) Abstract. The Cochrane Library, Issue 2

11. Hawkins RJ, Kennedy JC. 1980; Impingment syndrome in athletes. Am J, Sports Med.; 8: 151-158.

12. Horseley I, 2005; Assessment of Shoulder with pain of a non-traumatic origin. Physical Therapy in Sport, Vol 6, Issue 1, pg 6-1

13. Itoi E,Kido T,Sano A, et al. 1999; Which is more useful, the full can test or the empty can test in detecting the torn supraspinatus tendon ? Am J Sports Med.; 27: 65-68.

14. Kibler WB, McMullen J, Uhl T, 2001; Shoulder Rehabilitation Strategies, Guidelines and Practice (Abstract); Orthop. Clin. North Am. Jul., 32(3)

15. Koesler MC et al, 2005; Shoulder Impingement Syndrome. American Journal of Medicine, Vol 118, Issue 5, pg 452-455

16. Mosely JB, Jobe FW, Pink M, Perry J, Tibone J. 1992; EMG analysis of the scapular muscle during a shoulder rehabilitation program. Am J Sports Med; 20: 128-134.



17. Patrick J. McMahon, MD; Robert E. Salis, MD (1999) Post Grauate Medicine, Vol 106/ No. 7

18. Sherman SC, OConnor M, 2005; An Unusual Cause of Shoulder Pain: Winged Scapular; Journal of Emergency Medicine, Vol 28, pg 329-331

19. Solem-Bertoft E, Thoumas KA, Westerberg C-E, 1993

20. Solem- Bertot E, Thomas K-A, Westerberg C-E. 1993; The influence of scapular retration and protraction on the width of the subacromial space: An MRI study Clin. Orthop..; 296: 99 103

21. Towsend H, Jobe FW, Pink M PerryJ. 1991; Electromyographic anylisis of the glenohumeralmuscle during a baseball rehabilitaionprogram. AmJ Sport Med.; 19:264-272.

22. Van der Heijden GJM, Van der Windt DAW, De Winter AF (1997). Physiotherapy for patient with soft tissue disorders: a systemic review of randomized clicnical trials, BMJ, 315: 25-30

23. Walker N, Korell M, Thren K. 1998; Dymanic glenohumeral joint stability. J Shoulder, elbow surgical.; 7: 43-52

24. Warner JP, Micheli LJ, Arslanian LE, et al. 1990; Patterns of flaxity and strength in normal shoulders and shoulders with instability and impingement. Am J Sports Med.; 18: 366-375.

25. Diane Lee : The Pelvic girdle An Approach to the examination and treatment of the lumbopelvic hip region Churchill livingstone third edition

26. Nicola J Petty and Ann P Moore : Neoromusculoskeletal Examination and Assessment, a handbook for therapist.Churchill Livingstone 2001 2nd edition

.



15. GLOSSARY

1. Close Kinetic Chain exercises -

To any exercise in which the limb is restrained against an immobile object e.g. the ground.

2. Co-morbid -

Associated diseases

3. Disability -

Inability to perform an activity in the manner or to the extent considered normal

to that person such as problem in maintaining sitting position, picking object from the floor and standing up from lying position.

4. Hill Sach Deformity -

Indentation or groove on posterolateral aspect humeral head probably due to

compression of humeral head on posterior tip of glenoid. May occur after one

episode of shoulder dislocation.

5. Little league shoulder -

Repetitive force applied to the open proximal humeral epiphysis which causes

accelerated growth with widening, demineralization and apparent

fragmentation of the epiphysis. Probably caused by an epiphyseal

microfracture.

6. Lysis -

The destruction of cells through damage or rapture of the plasma membrane,

allowing escape of the cells contents.

7. Neuralgic amyotrophy (Parsonate-Turner Syndrome) Characterized by severe pain across the shoulder and upper arm followed by

atrophic paralysis in muscles around the shoulder.

8. Open Kinetic Chain exercises -

The distal end of the extremity is not fixed, allowing the joint to function independently without necessarily causing motion at another joint.



9. Osteochondromatolis -

A disorder of a joint featuring a change of a normal joint lining (Synovium) tissues cellular structure to form bone cartilage tissue.

10. Osteopenia -

A condition of bone in which decreased calcification, decreased density, or

reduced mass occurs.

11. Pancoasts tumour -

A type of tumour in the lungs.

12. Sclerosis -

Hardening of tissue usually due to scarring (fibrosis) after inflammation or to ageing.

13. Sulcus sign -

Apperance of a transverse sulcus (divot) between the humeral head and acromion when the arm is pulled longitudinally. A sign of inferior laxity or

multidirectional instability (MDI) of the shoulder. 14. Weight lifters osteolysis

Chronic compressive forces placed on the joint with weight lifting, both on the job and in recreational exercise programmes can cause progressive deterioration of the joint.



16. APPENDIX HEADINGS

A Causes of shoulder pain

B Special test

C Testing for muscle weakness

D Passive movements and active exercises

E Dynamic scapula stabilisation exercises

F Functional shoulder exercises

G Stabilization exercises

H Patient Education

I DASH disability/ symptom score



Appendix A

Causes of shoulder pain

Rotator cuff or biceps tendon

Strain

Tendinitis

Tear

Glenohumeral (GH) instability Anterior

Posterior

Multidirectional

GH instability with secondary impingement

Primary impingement of the cuff of biceps tendon

Calcified tendinitis

AC joint pathology Athritis

Separation

Weight lifters osteolysis

GH arthritis

Rheumathoid arthritis

Septic arthritis

Inflammatory arthritis

Neuropathic (Charcot) arthritis Crystaline arthritis (gout, pseudogout ) Haemophilic arthritis

Osteochondromatosis

Thoracic outlet syndrome

Cervical spine/ root/ brachial plexus injury with referred pain



Suprascapular nerve neuropathy

Shoulder dislocation

Acute

Chronic (missed) Scapuloclavicular injury Adhesive capsulitis (Frozen shoulder) SLAP lesion (superior labrum from anterior to posterior) Fracture

Humerus

Clavicle

Scapula

Scapular winging

Little league shoulder

Reflex sympathetic dystrophy

Thoracic spine dysfunction

Pelvic dysfunction

Foot mechanic dysfunction

Tumour

Metastatic

Primary

Multiple myeloma

Soft tissue neoplasm

Bone disorders

Osteonecrosis Arterial Vascular Necrosis (AVN) Paget s disease

Osteomalacia

Hyperparathyroid disease



Infection

Intrathoracic disorders (referred pain) Pancoasts tumour

Diaphragmatic irritation, Esophagitis

Myocardial infarction

Psychogenic disorders

Polymyalgia rheumatica

Neuralgic amyotrophy (Parsonage Turner syndrome) Abdominal disorders (referred pain )

Gastric ulcer

Gall bladder

Subphrenic abscess

Fibromyalgia



Appendix B

SPECIAL TEST

Supraspinatus test The patients arms are brought into 90 of forward flexion and then into 30 of horizontal abduction The arms are then internally rotated so the thumb are pointed downward. The therapist applies downward pressure while the patient resists and a positive response is if there is pain / weakness, indicating supraspinatius involvement.

Drop arm test - also a test for rotator cuff tear (especially the supraspinatus) The therapist passively abducts the arm to about 90 and then has the patient to slowly lower the arm to their side. A positive test is if the patient is unable to lower arm or is able to do so with considerable pain and shoulder hiking. Another possible result is he is unable to actively lower the arm but is able to hold it at shoulder height, if the therapist gives a light tap on the wrist the arm will fall.

Speed test (Bicep long head) the therapist resist forward flexion with the arm in supination and the elbow completely extended. Pain and weakness in the bicipital groove indicates a bicep strain or bicipital tendinitis.

Hawkins Impingement sign the arm is flexed forward to 90 passively, the proximal humerus is internally rotated with the elbow bend and a positive sign is if the patient complaints of reproducible pain at the subacromial space. An alternative method is to forward flex the arm to its overhead end-range and then forcibly put over pressure to the arm trying to jam the greater tuberosity into the acromion. It is indicates coracoacromial arch impingement at the rotator cuff.



Passive Cross-chest Adduction test The arm is brought to 90 of forward flexion. With subjects trunk stabilized by therapists hand on the posterior aspect of shoulder, grasp elbow and maximally horizontally adduct the shoulder.

Superior shoulder pain is indicative of AC joint pathology Anterior pain is indicative of subscapularis, supraspinatus

and/or biceps long head pathology Posterior shoulder pain is indicative of infraspinatus, teres

minor and/or posterior capsule pathology.

Anterior Drawer (To test right shoulder) The patient is examined supine, with the therapist standing at the affected shoulder. The right hand of the patient is held under the therapists axilla, clamped against the side. The shoulder is held in 80 to 120 of abduction, 0 to 20 of flexion and 0 to 30 of lateral rotation. The therapist holds the patients scapula with his left hand while grasping the patients upper arm and draws the humeral head anteriorly with his right hand.

Posterior Drawer The patient is supine. The therapist grasps the subjects elbow with one hand and stabilizes the ipsilateral and involved shoulder with the other hand. The subjects involved shoulder is placed in a position of 90 flexion and internal rotation, while applying a posterior force through the long axis of the humerus. In a positive test the patient either looks or expresses feeling of apprehension towards further movement in the posterior direction. The therapist also notes any posterior movement of the humeral head. Increased posterior instability of the humeral head relative to the scapula/glenoid fossa may be indicative of posterior instability.



Appendix B

ADVERSE NEURAL TENSION TEST ULTT

ULTT 1 (Median Nerve Bias) Starting Supine lying with no pillow. Therapist stands by the head side facing the patients feet. Technique

Ensure constant stabilization of shoulder girdle with left hand, with right hand holding the wrist and hand of patient.

Abduct arm to approximately 110 degrees, just below coronal plane

Add forearm supination Add wrist and finger extension Add glenohumeral external rotation Add elbow extension

Implications: Stress on the anterior interroseous nerve or median nerve C5, C6, and C7

ULTT 2B (Radial nerve bias) USES: This variation may be used when the subjective assessment indicates symptoms with a radial nerve bias. PATIENT: Lying diagonally supine with shoulder joint off the edge and arm in abduction to clear bed. PHYSIOTHERAPIST:

- Facing patients feet with closest thigh controlling the scapular depression and protraction.

- Arms crossed so one hand holds the wrist and the other the elbow.

Technique: depress and protract shoulder using thigh add elbow extension add internal rotation of whole arm pronate forearm add wrist and finger flexion add further adduction of forearm

Implications: Stress on the anterior radial nerve.



ULTT3 (Ulnar nerve bias): USES: This variation may be used when the subjective assessment indicates symptoms with an ulnar nerve bias (medial elbow pain, symptoms ulnar border hand, low cervical problem, C8 nerve root. PATIENT: Supine lying with no pillow. PHYSIOTHERAPIST: Facing the patient in stride standing, one hand over the patients hand, the other hand is on the patients shoulder. Technique:

wrist and finger extension forearm pronation Elbow flexion. shoulder girdle depression shoulder lateral rotation shoulder abduction until hand over ear

Implications: Stress on the ulnar nerve, nerve roots C8 and T1.

SACRO ILIAC JOINT STABILIZATION TESTS

Standing Hip Flexion ( Gillet test) The subject stands with sacroiliac joint (SIJ) exposed. The therapist is behind the subject with the thumbs over the PSISpines. Note if the PSISpines are level. If not level it indicates that the SI joint are asymmetrical, indicating fixation on one side. The therapist than places one thumb on the PSIS on the right side and the other thumb over the S2 spinous process. The subject is asked to flex his right hip actively to 90 with knee bent to 90. The thumb over the PSIS should move inferiorly. If there is no change or the thumb moves superiorly, it indicates a fixation or hypomobility. Repeat the same on the other side.



Prone hip extension test The patient lying prone is asked to lift one leg at the hip. The activity of the contralateral latismus dorsi is observed. If there is improper closure at the sacroiliac joint the contralateral latisimus dorsi attempts to stabilize the lower spine. This demonstrates the link between force closure at the sacroiliac joint and shoulder function.

Active Straight Leg Raising test

The supine patient is asked to lift the extended leg off the table, the compensation strategies at lumbo-pelvic hip region is noted. .Effort difference between the left and right leg (does one leg seem heavier or harder to lift?) is also noted .The strategies used to stabilize the thorax, the lower back and the pelvis during the task is observed .The leg should flex at the hip joint and the pelvis should not rotate laterally or tilt anteriorly or posteriorly relative to the lumbar spine. Proper activation of the muscles (both in the local and global system) is required for optimal function for the leg to rise effortlessly from the table. The application of compression to the pelvis reduces the effort necessary to lift the leg for patient with pelvic pain and instability. By varying the location of this compression during the ASLR, further information can be gained to assist in the prescription of the exercise to improve motor control and stability. If the compression force make a leg lighter / effortless it is a force closure (muscles) problem. If no change in effort check for form closure problem.



Appendix C

TESTING FOR MUSCLE WEAKNESS

Lift-off the back to evaluate the subscapularis portion of the

rotator cuff.

Testing internal rotators by resisting at the wrist

The external rotators are tested for weakness by resisting

external rotation at the wrist.



Serratus anterior standing with shoulders flexed to 90 push

against the wall.

Inferior trapezius prone lying , arms elevated, lift both arms up

towards ceiling

Rhomboids prone lying, arms heave position, lift arms up

towards ceiling



Appendix D

PASSIVE MOVEMENTS AND ACTIVE EXERCISE

Internal rotation

External rotation

Elevation

Horizontal adduction / abduction

Pendular exercise

Exercises with stick



STRETCHING EXERCISE

Stretching Inferior capsule of shoulder and latissimus dorsi muscle

Stretching Posterior capsule of shoulder and posterior fibers of deltoid muscle

Stretching Anterior capsule of shoulder and pectoralis major muscle

Stretching inferior capsule and rhomboid muscle

Stretching of levator scapulae Stretching of the upper trapezius



Appendix E

Dynamic Scapula Stabilization Exercises - Muscle strengthening exercises

CLOSE KINETIC CHAIN EXERCISE

Isometric Internal Rotators Isometric External Rotators

Isometric Flexors Isometric Extensors

Isometric Abductors



CLOSE KINETIC CHAIN SCAPULA STABILIZATION

Lean forward on table Wall Push-ups

Prone kneeling lean forward on hands, hold for 5 seconds,

Press-ups Sit on chair or table and place both hands firmly on the sides of the chair or table, slowly push downward on hand to elevate body



Appendix E

DYNAMIC SCAPULA STABILIZATION

Prone lying over ball, lean forwards on both hands

Prone lying over ball, lean forwards on affected arm and reach forward with the other

Ball rolling on table

Ball rolling on wall



Appendix E

OPEN KINETIC CHAIN ACTIVE FREE EXERCISES (TO IMPROVE STABILITY OF SCAPULA)

1. Prone lying , pillow under abdomen,

forehead resting on towel, arms at side,

lift towards ceiling, hold 3-5 seconds

2. Arms at 90 deg. , thumbs to ceiling

(ext. rotation), lift towards ceiling hold for 3-5 seconds

3. Arms at 120 deg., thumbs to ceiling, lift

towards ceiling, hold for 3-5 seconds

3. Arms heave position, lift arms towards

to ceiling,hold 3-5 seconds

Exercise 1 to 4: Initially start in supine and progress to prone when there is improved scapula

control, repeat 5 times



Movement in PNF pattern (Flexion, abduction and external rotation)

Rowing exercise Starting position - Ending position

*Weight or theraband may be used as a progression in this exercise



OPEN CHAIN STRENGTHENING EXERCISES WITH RESISTANCE

scapula retraction

overhead throwing

External rotation with resistance ( using theraband )

Internal rotation with resistance ( using theraband ) Strengthening serratus anterior with dumbbell or water filled bottle



Appendix F

FUNCTIONAL EXERCISE

Reaching-forward, above head

Ball throwing in different directions



Appendix G

STABILIZATION EXERCISE : CORE STABILIZATION AND OBLIQUE CHAIN EXERCISES

Vojta reflex rolling dead cockroach

a). Upper limb supported in scaption position (shoulder held in 30 abduction and forward flextion 60) Lower limb : hip flexion abduction and external rotation Tuck in chin, belly button in and elongate your tail bone. (with upper limb and lower limb supported)

b). Lower limb unsupported

c) Keep chin tucked in with tail bone elongated, rotate trunk to bring alternate elbow and knee together.

d) Rotate both legs side to side. (cockroach with rotation)



VOJTA REFLEX CRAWLING MAD

ROOSTER

Principle of joint centration. This position bring about the reflex activation of deep neck flexor and lower rib cage

.



Appendix H

Patients Education

Explain the nature of injury The nature of the injury should be explained

Advise related to the individual requirement:

Sleep-positions so that the shoulder is well supported

Exercises to be performed daily and regularly through optimal range

of motion within limits of pain

If pain persists at night, apply ice pack / hot pack for 10 20 min

Avoid sudden shoulder movement during functional activities.

Avoid overly aggressive exercise regime. Do not increase exercise

duration or intensity more than 10% per week.

Work

Modify work activities if necessary. Avoid overusing your arm in an

overhead position or keep repetitive overhead to a minimum.

Do not ignore or try to work through pain.

Posture

Maintain good posture at all time.

Relaxation practice should go together with the postural training.

Other advice

Be active within limits of pain.

Rest only when joint is very painful. Continue as much of your normal routine as possible.



Appendix I

DASH DISABILITY/SYMPTOM SCORE

Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.

NO

DIFFICULTY

MILD

DIFFICULTY

MODERATE

DIFFICULTY

SEVERE

DIFFICULTY

UNABLE

1. Open a tight or new jar 1 2 3 4 5 2. Write. 1 2 3 4 5 3. Turn a key. 1 2 3 4 5 4. Prepare a meal. 1 2 3 4 5 5. Push opens a heavy door. 1 2 3 4 5 6. Place an object on a shelf above your head 1 2 3 4 5 7. Do heavy household chores (e.g., wash walls, wash floors).

1 2 3 4 5

8. Garden or do yard work. 1 2 3 4 5 9. Make a bed. 1 2 3 4 5 10. Carry a shopping bag or briefcase. 1 2 3 4 5 11. Carry a heavy object (over 10 lbs). 1 2 3 4 5 12. Change a light bulb overhead. 1 2 3 4 5 13. Wash or blow-dry your hair. 1 2 3 4 5 14. Wash your back. 1 2 3 4 5 15. Put on a pullover t-shirt. 1 2 3 4 5 16. Use a knife to cut food. 1 2 3 4 5 17. Recreational activities which require little

effort (e.g., card playing, knitting, etc.).

1

2

3

4

5 18. Recreational activities in which you take

some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).

1

2

3

4

5

19. Recreational activities in which you move your arm freely (e.g., playing Frisbee, badminton, etc.).

1 2 3 4 5

20. Manage transportation needs (Getting from one place to another).

1 2 3 4 5

21. Sexual activities. 1 2 3 4 5 NOT AT ALL SLIGHTLY MODERATE QUITE A BIT EXTREM

ELY

22. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbors or groups? (Circle number

1

2

3

4

5

NOT LIMITED

AT ALL

SLIGHTY

LIMITED

MODERATELY

LIMITED

VERY

LIMITED

UNABLE

23. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem? (circle number) 1 2 3 4 5. Please rate the severity of the following symptoms in the last week.

1

2

3

4

5

NONE

MILD MODERATE SEVERE EXTREM

E

24. Arm, shoulder or hand pain. 1 2 3 4 5 25. Arm, shoulder or hand pain when you performed any specific activity.

1 2 3 4 5

26. Tingling (pins and needles) in your arm, shoulder or hand.

1 2 3 4 5



27. Weakness in your arm, shoulder or hand. 1 2 3 4 5 28. Stiffness in your arm, shoulder or hand. 1 2 3 4 5 NO

DIFFICULTY

MILD

DIFFICULTY

MODERATE

DIFFICULTY

SEVERE

DIFFICULTY

SO

MUCH

DIFFICUL

TY THAT

I CANT

SLEEP

29. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number)

1

2

3

4

5

STRONGLY

DISAGREE

DISAGREE NEITHER

AGREE NOR

DISAGREE

AGREE STRONG

LY

AGREE

30. I feel less capable, less confident or less useful because of my arm, shoulder or hand problem. (circle number

1

2

3

4

5

THE ARM, SHOULDER AND HAND

DASH DISABILITY/SYMPTOM SCORE

= (Sum of n responses - 1) x 25 n

where n is equal to the number of completed responses.

A DASH score may not be calculated if there are greater than 3 missing items

Eg. If a patient responded with a score of 4 in all 30 questionaires of activities, the total

will be : n=30 Sum of responses = 30x4

Score = (30x4) - 1 x 25 = 75% 30



INTERPRETATION OF DASH DISABILITY SYMPTOM SCORE

The higher the percentage scored, the more disabilities the patient has

PERCENTAGE SCORE

LEVEL OF DISABILITIES

80 % - 100 %

Extreme Disabilities

60 % - 79 %

Severe Disabilities

40 % - 59 % Moderate Disabilities

20 % - 39 %

Mild Disabilities

0 % - 19 %

No Disabilities

Patient can be discharged at mild or no disabilities in Dash Disability Symptom Score, with consideration that other associated problems of neck, thoracic and lower quadrant (lumbar, pelvis, hip and lower limb) have been addressed in the management of shoulder problem.



Editors

Y. Bhg. Datin Hjh. Asiah Mohd. Hashim Bsc (Hons) App Rehab PT UK, Dep in PT- KKM Cert Sports PT Uni Melb Ketua Profesyen Fisioterapi Pegawai Pemulihan Perubatan (Anggota ) Gred U44 Hospital Kuala Lumpur

Encik Daaljit Singh H. S. Bsc (Hons) App Rehab PT UK, Dip PT - KKM, Dip Acu Colombo, M.D.(M.A.) Colombo Cert Councelling KKM Cert Sports PT Uni Melb, Jurupulih Perubatan (Anggota) Gred U38 Hospital Raja Permaisuri Bainun, Ipoh, Perak

Puan Sarkuna Devi Premnath Dep in PT- KKM Graduate Cert. In Applied Sc ( PT) - Uni Sydney, NSW Aus. Jurupulih Perubatan (Anggota) Gred U40 Hospial Tengku Ampuan Rahimah, Klang, Selangor.

Pn. Gan Pein Pein Dep in PT- KKM Postgrad program ( Mckenzie Inst. International ) Jurupulih Perubatan (Anggota) Gred U36 Hospital Kuala Lumpur.



Contributors

Y. Bhg. Datin Hjh. Asiah Mohd. Hashim Ketua Profesyen Fisioterapi Pegawai Pemulihan Perubatan (Anggota ) Gred U44 Hospital Kuala Lumpur

Encik Daaljit Singh H. S. Jurupulih Perubatan (Anggota) Gred U38 Hospital Raja Permaisuri Bainun, Ipoh, Perak

Puan Sarkuna Devi Pramnath Jurupulih Perubatan (Anggota) Gred U40 Hospial Tengku Ampuan Rahimah, Klang, Selangor

Pn. Gan Pein Pein Jurupulih Perubatan (Anggota) Gred U36 Hospital Kuala Lumpur

Pn. Hjh. Normah Abd. Jamil Pegawai Pemulihan Perubatan (Anggota) Gred U41 Hospital Tuanku Fauziah, Kangar Perlis

Pn Yew Su Fen Pegawai Pemulihan Perubatan (Anggota) Gred U41 Hospital Pulau Pinang, Pulau Pinang

Cik Catherine Wong Pick Yieng, Pegawai Pemulihan Perubatan (Anggota ) Gred U41 Hospital Sibu, Sarawak

En Md Yunus Sufaat Pegawai Pemulihan Perubatan (Anggota ) Gred U41 Program Fisioterapi, Kolej Sain Kesihatan Bersekutu, Johor Bharu Johor

Cik Se To Phui Lin Pegawai Pemulihan Perubatan (Anggota ) Gred U41 Hospital Kuala Lumpur

Pn Halimah bt Hashim Pegawai Pemulihan Perubatan (Anggota) Gred U41 Hospital Raja Perempuan Zainab II Kota Bharu, Kelantan

Pn. Jamaliah Musa Jurupulih Perubatan (Anggota) Gred U40 Hospital Umun Sarawak, Kucing, Sarawak

Pn. Hjh. Hanisah Mhd. Noor Jurupulih Perubatan (Anggota) Gred U40 Hospital Sultanah Aminah, Johor Bharu, Johor

Pn. Ruhaya Hussien Jurupulih Perubatan (Anggota) Gred U38 Hospital Tuanku Jaafar, Seremban, N. Sembilan ( Retired in 2009 )



Pn. Mariam Mohd. Nawang Jurupulih Perubatan (Anggota) Gred U38 Hospital Sultanah Aminah, Johor Bharu, Johor

Pn Siti Mariah Seman Jurupulih Perubatan (Anggota) Gred U38 Hospital Tengku Ampuan Rahimah, Klang, Selangor

Cik Mary Tharsis Jurupulih Perubatan (Anggota) Gred U36 Hospital Kuala Lumpur (Currently in Sunway Medical Centre)

Pn. Kanagambegai a/p Manickam Jurupulih Perubatan (Anggota) Gred U36 Hospital Melaka, Melaka

En. Jumat Pani Jurupulih Perubatan (Anggota ) Gred U36 Hospital Queen Elizabeth, Kota Kinabalu, Sabah

Tuan Hj. Mat Som Ahmad Jurupulih Perubatan (Anggota) Gred U32 Hospital Teluk Intan, Perak

En. Rajpal singh Jurupulih Perubatan (Anggota) Gred U36 Hospital Pulau Pinang, Pulau Pinang

En. Hairul Hapizi Samaon Jurupulih Perubatan (Anggota) Gred U36 Hospital Sungai Buloh, Selangor

En. Mohd. Solihin Ali Hassan Jurupulih Perubatan (Anggota ) Gred U29 Hospital Kuala Lumpur

.

Documents

Physiotherapy Care Protocol for Shoulder Pain Update May