SYMPTOMS & HISTORY

ASSOCIATED WITH IMPINGEMENT

• Pain in ant/post shoulder or deltoid area
• Pain w/overhead activities
• Unable to sleep on affected side

ASSOCIATED WITH TOS

• May experience numbness/tingling in hand
• May experience decreased circulation or feeling of coldness or whole arm falling asleep w/arms overhead
• Pain in interscapular area, medial arm, forearm and hand

ASSOCIATED WITH INSTABILITY

• “Clunking” with arm movements or sensation of shoulder slipping out of socket

ACTIVITIES

• Jobs req. Sustained arm positions at 90 degrees shoulder flexion
• Swimmers
• Weight lifters
• Laborers
• Kayakers
• Cross-country skiers

KEY TESTS & SIGNS

ALIGNMENT AND APPEARANCE

• Inferior angle of scapula protrudes from thorax
• Vertebral border of scapula protrudes from thorax
• Correction of alignment impairment decreases symptoms; if assoc w/tos, distal symptoms
• May increase w/correction of scapular impairment

MOVEMENT IMPAIRMENTS

ASSOC W/WEAKNESS OF SERRATUS ANTERIOR:

• Pronounced scapular winging noted during arm elevation and during return; correction decreases symptoms
• May note scapular adduction during arm elevation
• Scapula will not achieve 60 degrees upward rotation at end-range shoulder flexion/abduction

MOVEMENT IMPAIRMENTS WITHOUT PROFOUND WEAKNESS

• Winging /tilting of scapula noted only on return from arm elevation; correction decreases symptoms
• Scapula and humerus move in 1:1 ratio during arm elevation
• Insufficient scapular posterior tilt at end-range arm elevation; correction decreases symptoms

LIFTING AND HOLDING

• Unable to maintain proper scapular alignment (winging/tilting) during lifting or when loads are added to arm
• Assoc w/weakness of serratus anterior

IMPAIRMENTS IN STRENGTH

• Weak/long/paralyzed serratus ant.

IMPAIRMENTS IN MUSCLE LENGTH

BASED ON LENGTH TESTS:

• Short pec min/maj, sh, biceps
• Based on alignment:
• Long lower/middle trap (primarily lower)

ASSOCIATED SIGNS

ALIGNMENT AND APPEARANCE

• May have normal resting alignment
• May have downwardly rotated scapula
• Heavy arms
• Large breasts
• Hypertrophy of rhomboid muscles

STRUCTURAL VARIATIONS

• Long arms
• Flat thoracic spine (winging)
• Scoliosis
• Thoracic kyphosis (tilting)

COMMON ACTIVITIES

• Sit w/slouched posture
• Activities req. Reaching forward
• Assoc w/profound weakness of serratus anterior

IMPAIRMENTS IN LENGTH

• Based on alignment or passive movement:
• May develop shortened trapezius, rhomboids; lengthened serratus anterior

MOVEMENT IMPAIRMENTS

• Shoulder flexion
• Assoc w/impingement: may have slight end-range limitation; may have painful arc
• Assoc w/tos:  may have numbness/tingling or other symptoms during arm elevation
• Assoc w/instability:  may observe increased crease distal to acromiom; may also observe increased prominance of humeral head in axilla

PALPATION

• Assoc w/impingement:  may be tender over coracromial lig., bicipital groove, rotator cuff tendons (supraspinatus)
• Assoc w/tos:  may be tender over scalenes/pec minor

SPECIAL TESTS

• Assoc w/impingement:  tests reproduce pain; resisted test of rotator cuff and biceps for soft tissue diff dx may be strong/weak and painful
• Assoc w/tos: may reproduce symptoms
• Assoc w/instability:  may have increased accessory glide at gh in any direction

DIFF MVMT & ASSOC DX

DIFFERENTIAL SCAPULAR DX

• Scapular downward rotation
• Scapular abduction

DIFFERENTIAL PRIMARY DX

• Humeral anterior glide
• Humeral superior glide
• Humeral medial rotation

ASSOCIATED DX

• Rotator cuff tendinopathy
• Shoulder impingement
• Partial rotator cuff tear
• Bicipital tendinopathy
• Supraspinatus tendinopathy
• Humeral subluxation
• Tos and neural entrapments
• Neck pain w/wout radiating pain
• Pain or trigger points in rhomboids
• Bursitis
• Ac joint pain
• Calcific tendinopathy
• Subscapular bursitis
• Snapping scapulae
• Cervical or cervical thoracic junction pain
• Long thoracic nerve injury

MED DX REQ. REFERRAL

MUSCULOSKELETAL ORIGIN

• Long thoracic nerve palsy
• Cervical radiculopathy
• Brachial plexus injury
• Rotator cuff tear
• Fracture
• Oa or ra
• Glenoid labrum tear
• Peripheral nerve entrapment
• Spinal accessory nerve palsy

VICERAL ORIGIN

• Neoplasms
• Cardiovascular disease
• Pulmonary disease
• Breast disease
• Abdominal organ abnormality

SYSTEMIC ORIGIN

• Collagen vascular disease
• Gout
• Syphilis and gonnorhea
• Sickle cell anemia
• Hemophilia
• Rheumatic disease

MOVEMENT TX

SUPINE POSITION

• Shoulder medial rotation keeping the scapulae still
• Emphasis on stretching pec minor and strengthening lower trapezius
• Correct abdominal muscle imbalances
• Assisted pec maj/min stretch

QUADRUPED POSITION

• Quadruped rocking with emphasis on  allowing thoracic spine to flatten

STANDING POSITION

• Back to wall perform shoulder flexion and abduction with elbows flexed to 90˚…at end range place hands on head and laterally flex to stretch abdominals