Shoulder Pain

Stuart Williams, D.O.Associate Professor

Osteopathic Manipulative Medicine

Evaluation of Shoulder

Glenohumeral Joint Acromioclavicular Joint Sternoclavicular Joint T1-T4 Ribs 1-4

Patient abducts arms and extends pronated hands over head

Negative Test Upper arms should touch ears Elbows straight. Forearms pronated. Back hands approximate equally. Joints of shoulder, elbow, radioulnar, and wrist

are normal. Positive Test

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

Upper Extremity Motion Test

Rotator Cuff MusclesSITS

Supraspinatus-abductionInfraspinatus-ext.rotationTeres Minor-ext. rotation

Subscapularis-int. rotation

Special TestsApley Scratch Test and Shoulder ROM

External Rotation & ABduction

Internal Rotation & ADduction

Internal Rotation & ADduction

Shoulder Range of Motion

Glenohumeral and Scapulothoracic Joint ABduction ADduction Flexion Extension Internal Rotation External Rotation

180º30-

45º90º45-

50º55º40-

45º

Special TestsRotator Cuff Pathology

Arm drop Test (Empty Can Test)

Adhesive Capsulitis“frozen shoulder”

Gradual loss of function Decreased ROM - Active and

Passive External Rotation Internal Rotation ABduction

Diffuse tenderness

Inflammation Fibrous changes in periarticular

soft tissue Decreased joint volume -

confirmed by arthography

Seven Stages of Spencer

Excellent way to examine shoulder while treating

Seven Stages of Spencer

1. Extension 2. Flexion 3. Circumduction with Compression 4. Circumduction with Traction 5. Abduction 6. Internal Rotation 7. Joint Pump

Technique (Muscle Energy) 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 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 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 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

counter-clockwise in a cone shape Any areas of resistance-modify elbow

pressure and change circumference of cone

Stage 4 – Circumduction with Traction 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 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 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

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

1. Extension 2. Flexion 3. Circumduction with Compression 4. Circumduction with Traction 5. Abduction 6. Internal Rotation 7. Joint Pump