The primary movement impairment in this syndrome is insufficient scapular elevation.  Initial scapular alignment may be depressed with a failure to elevate sufficiently during movement, or scapular alignment may be normal. Depression occurs during arm elevation.  Muscle impairments include dominance, shortness, or stiffness of the scapular depressor muscles [e.g., latissimus, pecs, lower trapezius], and insufficient activity or lengthened scapular elevator muscles [e.g., upper trapezius and possibly levator scapula]. (Sahrmann, 2002)

SYMPTOMS & HISTORY

ASSOCIATED WITH IMPINGEMENT

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

ASSOCIATED WITH TOS

• Numbness/tingling in hand possible
• Decreased circulation/coldness or arm falling asleep w/arms overhead
• Pain in interscapular area, medial arm, forearm and hand

ASSOCIATED WITH UPPER TRAPEZIUS STRAIN

• Pain in upper trap area
• May be associated w/neck pain and headaches

ASSOCIATED WITH INSTABILITY

• “clunking” w/arm movements or sensation of shoulder slipping out of socket

ACTIVITIES

• Weight lifters/heavy laborers
• Computer keyboard techs
• String instrument musicians
• Mothers of newborns
• Women in jobs req. Lifting
• Ballet dancers
• Gymnasts
• Jobs req. Sustained arm positions at 90 degrees shoulder flexion

KEY TESTS & SIGNS

ALIGNMENT AND APPEARANCE

• Slope of shoulder girdle increased
• Scapulae lower than t2-t7
• Neck appears long
• Clavicular angle lower than normal
• If unilateral, one arm appears longer than the other
• Correction of alignment impairment decreases symptoms…if assoc/w tos, symptoms may increase

MOVEMENT IMPAIRMENTS

• Shoulder flexion:  insufficient scapular elevation…correction of depression decreases symptoms
• Lifting or holding:  patient unable to maintain correct scapular elevation during lifting or when loads are added to arm

MUSCLE LENGTH IMPAIRMENTS

• Based on alignment:  long upper trap, levator scap
• Based on length tests:  short lat, pecs

MUSCLE STRENGTH IMPAIRMENTS

• Weak/long/strained upper/middle trap

Associated Signs

ALIGNMENT AND APPEARANCE

• May have normal resting alignment
• Large breasts
• Heavy arms

STRUCTURAL VARIATIONS

• Long arms
• Long neck
• Long trunk
• Short arms

COMMON ACTIVITIES

• Habitual depression of shoulder girdle
• Computer keyboard too low
• Armrests on chair too low

MOVEMENT IMPAIRMENTS

• Shoulder flex assoc/w impingement:  may have slight end-range limit/painful arc
• Shoulder flex assoc/w tos:  may have numb/tingling or other tos symptoms during arm elevation
• Shoulder flex assoc/w instability:  may observe increased crease distal to acromiom…may observe increased prominence of humeral head in axilla

PALPATION

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

SPECIAL TESTS

• Assoc/w impingement:  tests reproduce pain…resisted tests of rotator cuff/biceps for soft tissue diff diag may be strong/painful or weak/painful
• Assoc/w tos:  may reproduce symptoms
• Assoc/w instability:  may have increased accessory glide at gh joint in any direction
• Assoc/length impairments:  short lower trap/lat

DIFF MVMT & ASSOC DX

DIFFERENTIAL SCAPULAR DX

• Rule: if scap dep is assoc/w another scap movement impairment. Scap dep is is the dx if passive correction of dep alleviates symptoms
• Scapular downward rotation
• Scapular abduction
• Scapular wing/tilt

DIFFERENTIAL PRIMARY DX

• Humeral ant glide
• Humeral inf glide
• Humeral sup glide
• Cervical rot
• Cervical ext
• Cervical rot and ext

ASSOCIATED DX

• Rotator cuff tendinopathy
• Shoulder impingment
• Partial rotator cuff tear
• Bicipital tendinopathy
• Supraspinatus tendinopathy
• Humeral subluxation
• Tos and neural entrapments
• Neck pain w/wout radiating pain
• Pain/trigger pts in levator scap,rhomb, upper trap
• Bursitis
• Ac joint pain
• Calcific tendinopathy
• Subscapulr bursitis
• Snapping scap
• Drooping shoulder
• Long thoracic nerve injury
• Cervical or cervical/thoracic junction pain

MEDICAL DX REQ. REFERRAL

MUSCULOSKELETAL ORIGIN

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

VICERAL ORIGIN

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

SYSTEMIC ORIGIN

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

MOVEMENT TX

MAIN FOCUS

• Probable lack of physical activity suggests chronically underused and underdeveloped shoulder muscles
• Shoulder shrugging before lifting or holding and after lifting or holding
• Shoulder flexion with shrugging
• Just about any/all shoulder development exercises performed with appropriate shoulder stabilization