Excessive humeral medial rotation or insufficient lateral rotation is noted during shoulder flexion and abduction.  The shoulder medial rotators dominate over the lateral rotators. (Sahrmann, 2002)

SYMPTOMS & HISTORY

ASSOCIATED WITH IMPINGEMENT

• Pain most often in anterior shoulder but may also be posterior shoulder or deltoid
• Pain with overhead activitiesor with activities involving shoulder rotation w/arm elevated
• Unable to sleep on affected side

ACTIVITIES

• Weight lifters
• Heavy laborers
• Swimmers

KEY TESTS & SIGNS

ALIGNMENT AND APPEARANCE

• Humerus is medially rotated w/wout corrected scapular alignment

MOVEMENT IMPAIRMENTS

• Excessive humeral medial rotation noted during shoulder flexion and abduction
• Correction of excessive medial rotation may lessen pain
• May increase pain if capsular structures are shortened leading to increased compressive forces (e.g. superior glide)

SPECIAL TEST

• Accessory joint motion can be decreased posteriorly

IMPAIRMENTS IN MUSCLE LENGTH

• Based on length tests:  short medial rotators (e.g. teres major, latissimus dorsi, pectoralis major)

IMPAIRMENTS IN MUSCLE STRENGTH

• Weak lateral rotators

ASSOCIATED SIGNS

ALIGNMENT AND APPEARANCE

• May have normal resting alignment
• Humerus may be abducted
• Forward shoulder (abducted or tilted scapulae)
• Obesity

STRUCTURAL VARIATIONS

• Generalized muscle bulk
• Wide thorax
• Barrel chest
• Commonly assoc w/scapular syndrome

MOVEMENT IMPAIRMENTS

• Shoulder flexion
• Assoc w/impingement:  may have slight end-range limitation and may have painful arc
• Assoc w/instability:  during shoulder flexion see a sudden shift of humerus into medial  rotation

IMPAIRMENTS IN MUSCLE LENGTH

• Short or stiff deltoid
• Short lateral rotators

IMPAIRMENTS IN MUSCLE STRENGTH

• Weak subscapularis assoc w/ impingement

PALPATION

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

SPECIAL TESTS

• Impingement tests:  reproduce pain; resisted tests of rotator cuff and biceps for soft tissue diff dx may be strong/weak painful

DIFF MVMT & ASSOC DX

DIFFERENTIAL HUMERAL DIAGNOSIS

• Rule:  if shoulder medial rotators and superior glide co-exist, superior glide is dx

DIFFERENTIAL PRIMARY DIAGNOSIS

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

ASSOCIATED DIAGNOSES

• Rotator cuff tendinopathy
• Shoulder impingement
• Partial rotator cuff tear
• Bicipital tendinopathy
• Supraspinatis tendidopathy
• Bursitis
• Ac joint pain
• Calcific tendinopathy

MED DX REQ. REFERRAL

MUSCULOSKELETAL 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
• Syphlis and gonnorhea
• Sickle cell anemia
• Hempohilia
• Rheumatic disease

MOVEMENT TX

PRIMARY EMPHASIS

• Improve control of humeral lateral rotators
• If medial rotators are short they must be lengthened
• If teres major is short must be lengthened…must restrain scapula during shoulder flexion
• Improve control of gh lateral rotators (with resistive exercise) to maintain picr
• Scapula should not wing/tilt during  prone lateral rotation w/shoulder abducted to 90  and elbow flexed to 90… Only the humerus should move
• Teach shoulder packing…contracting scapular adductors and serratus anterior while minimizing the contribution of the gh lateral rotators