Excessive superior or insufficient inferior glide of the humeral head is noted during shoulder motions.  This may be associated with stiffness or shortness of the superior or inferior structures of the GH joint.  Insufficiency of the rotator cuff because of weakness, recruitment impairments, or tear is a major causative factor. This disrupts the normal force couple between the rotator cuff and the deltoid. (Sahrmann, 2002)

ASSOCIATED WITH IMPINGEMENT

• Pain in sup., ant., or post. shoulder or deltoid area
• Pain w/overhead activities or reaching out to the side
• Unable to sleep on affected side
• More common in middle aged to older people

ACTIVITIES

• Weight lifters and bodybuilders
• Swimmers

KEY TESTS & SIGNS

ALIGNMENT AND APPEARANCE

• Flattened deltoids:  (greater tuberosity not prominent, just distal to acromiom)
• Arms in abduction relative to scapulae
• Assoc w/downward scapular rotation
• Correction of scapular alignment results in humerus moving into abduction
• Hypertrophied deltoid:  arm rests in abduction

MOVEMENT IMPAIRMENTS

• Excessive humeral superior glide noted during shoulder abduction, flexion, and medial/lateral rotation
• Humeral superior glide more evident during active abduction versus passive
• Manual correction decreases symptoms…active correction by increasing rotator cuff and decreasing deltiod activity decreases symptoms
• Decreased gh crease noted just distal to acromiom w/arm overhead
• Decreased distance between humeral head and base of neck noted to end-range arm elevation

SPECIAL TESTS

• Accessory joint motion decreased inferior glide (more evident with 90 degrees arm abduction) and lateral distraction

IMPAIRMENTS IN MUSCLE LENGTH

• Based on length tests:  short subscap and lateral rotators
• Based on length tests:  shortness of supraspinatus, deltoid (limitation od humeral adduction)
• Based on alignment:  short deltoid and supraspinatus

IMPAIRMENTS IN MUSCLE STRENGTH

• Weak rotator cuff muscles

ASSOCIATED SIGNS

ALIGNMENT AND APPEARANCE

• Obesity
• May have normal resting alignment
• May see atrophy of rotator cuff muscles

STRUCTURAL VARIATIONS

• May have generalized increased muscle bulk

COMMON ACTIVITIES

• Repetitive arm activities
• Leaning on arms or elbows
• Commonly assoc w/scapular syndrome

MOVEMENT IMPAIRMENTS

SHOULDER FLEXION

• Assoc w/impingement:  may have slight end-range limitation and may have painful arc

IMPAIRMENTS IN MUSCLE LENGTH

• Based on length tests:  shortness of latissimus and teres major muscles

PALPATION

• May be tender over coracromial lig., bicipital groove or rotator cuff tendons

SPECIAL TESTS

• Assoc w/impingement:  tests reproduce pain; resisted tests for rc and biceps for soft tissue diff dx may be strong/weak and painful
• Drop arm; test may be positive
• Empty can test positive for reproduction of pain

DIFF MVMT & ASSOC DX

DIFFERENTIAL HUMERAL DIAGNOSIS

• Rule:  if superior and anterior glide co-exist, assign anterior glide
• Rule:  if shoulder medial rotation and superior glide co-exist, assign superior glide
• Humeral anterior glide
• Shoulder medial rotation
• Gh hypomobility

DIFFERENTIAL PRIMARY DIAGNOSIS

• Scapular downward rotation
• Scapular depression
• Scapular abduction
• Scapular winging and tilting

ASSOCIATED DIAGNOSIS

• Rotator cuff tendinopathy
• Shoulder impingement
• Partial or complete rotator cuff tear
• Bicipital tendinopathy
• Supraspinatus tendinopathy or tear
• Humeral subluxation
• Bursitis
• Ac joint pain
• Calcific tendinopathy
• Frozen shoulder and adhesive capsulitis
• Outlet syndrome (jobe)

MED DX REQ. REFERRAL

MUSCULOSKETAL ORIGIN

• Cervical radiculopathy
• Brachial plexus injury
• Rotator cuff tear
• Fracture
• Oa or ra
• Glenoid labrum tear

VICERAL ORIGIN

• Neoplasms
• Cardiovascular disease
• Pulmonary disease
• Breast disease
• Abdominal organ pathologic condition

SYSTEMIC ORIGIN

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

MOVEMENT TX

PRIMARY EMPHASIS

• Stretch deltoid…improve control of trapezius/serratus anterior

SUPINE POSITION

• W/shoulder abducted to 80˚ restrict all motion of humerus with contralateral hand while performing lateral and medial rotation

PRONE POSITION

• Practice medial rotation w/out allowing scapular motion or or superior glide of the humeral head

STANDING (FACING WALL)

• Patient performs shoulder flexion by sliding hand up the wall with light pressure to create downward force on the humerus while maintaining lateral rotation of the humerus and avoid ing medial rotation…
• After shoulders reach 160˚ of flexion lift arms away from wall by adducting and depressing scapula (improves performance of the trapezius and corrects abducted position of the scapula

STRETCH DELTOID

• Stand w/arm at side and use other hand to passively adduct the humerus