Excessive anterior or insufficient posterior glide of the of the humeral head is noted during shoulder motions.  This syndrome may be associated with laxity of the anterior structures and stiffness or shortness of the posterior structures of the GH joint.  The subscapularis is frequently lengthened or weak and the posterior deltoid dominates over infraspinatus and teres minor muscles.  The muscles that attach further from the axis of rotation (e.g., pectoralis major, latissimus, teres major) dominate over the subscapularis. (Sahrmann, 2002)

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