Physiotherapy Care Protocol For Shoulder Pain Update May

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KEMENTERIAN KESIHATAN MALAYSIA
PHYSIOTHERAPY
CARE PROTOCOL
FOR SHOULDER PAIN
TECHNICAL COMMITTEE
PHYSIOTHERAPY
PROFESSION
MINISTRY OF HEALTH
MALAYSIA 2011
Physiotherapy Care Protocol
PHYSIOTHERAPY CARE PROTOCOL FOR SHOULDER PAIN
CONTENTS
1
Definition
Overview
Signs and symptoms
Causes of shoulder pain
Investigation (Doctor)
Diagnostic Triage
Differential Diagnosis
Assessment
Goals of Treatment
10
Intervention
14
11
Discharge care plan
18
12
Supplementary notes
19
13
Algorithm
21
14
References
22
15
Glossary
24
16.
Appendix Headings
26
17.
Appendix A
27
18.
Appendix B
30
19.
Appendix C
35
20.
Appendix D
37
21.
Appendix E
39
22.
Appendix F
45
23.
Appendix G
46
24.
Appendix H
48
25.
Appendix I
49
26
Editors
52
27
Contributors
53
Working Committee, Physiotherapy Profession MOH February 2011
1. DEFINITION
Pain in the shoulder region can arise from the glenohumeral (GH) or acromioclavicular
(AC) joint, or from the periarticular structures or it may be referred from the neck,
thoracic or abdomen (Woodward TW & Best TM, 2000).
The term acute is defined as pain that is present for less than 3 months; it does not refer
to the severity or quality of pain.
Chronic pain is pain that has persisted for more than 3 months (Mersky & Bogduk,
1994).
2.
OVERVIEW
In government hospitals in Malaysia, shoulder pain is the second most common

musculoskeletal problem seen as outpatients in the physiotherapy departments.
(Statistics collected from physiotherapy departments, MOH Malaysia). As reported by
Cailliet, 1981, pain in the shoulder is the third most commonly experienced in
musculoskeletal pain. Shoulder pain is a common reason for seeking treatments as it
affects activities of daily living including sleep (van der Heijden 1999).
Many people with acute shoulder pain are likely to recover fully without treatment. It is
evidenced that 23% of all new episode of shoulder pain resolve fully within 1 month and
44% resolve within 3 months of onset (Van Der Windt et. al, 1996).
There is a risk that uncomplicated shoulder pain may persist beyond the acute phase
due to poor posture, coping styles and occupational factors (Van Der Heijden, 1999).
Early intervention is important to prevent progression to chronic stage.
3. SIGNS AND SYMPTOMS
Pain common symptom for all shoulder problems
Restricted movement
Swelling and warmth
Muscle spasm
Weak / inhibited muscles
Tight muscles
Stiffness
Looseness - Shoulder instability
Deformity of shoulder e.g. loss of contour, winging of scapula.
Crepitus popping / clicking could be due to cartilage or rotator cuff tear or

instability of shoulder
4.
CAUSES OF SHOULDER PAIN (Refer to Appendix A)

The most common disorders seen are :
1. Periarticular condition, especially Rotator Cuff lesion (tendinitis, cuff tear or
subacromial bursitis, impingement syndrome),
2. Soft tissue injuries affecting the shoulder girdle,
3. Shoulder instability (including labral damage and acromioclavicular (AC)
separation and Pectoral girdle nerve syndrome.
5.
INVESTIGATION BY DOCTOR
Some of the investigations carried out are
X-ray
Arthrogram
MRI
Arthroscopy
6.
DIAGNOSTIC TRIAGE
Classification
Impingement
Overused
X-Ray finding
Cause of
shoulder
pain
Findings consistent with

diagnosis
Findings
inconsistent
with diagnosis
Rotator cuff
Age usually over 40 years old, cuff
Acromial Spur,
Age below 30
disorder
weakness, atrophy, tenderness,
greater tuberosity
years old,
painful arc of motion, night pain,
sclerosis and
no upper arm
impingement sign, upper arm pain,
cysts, loss of
pain, no
and crepitus.
acromio-humeral
weakness,
interval (X-ray
no impingement
may be normal)
sign
Arthritis of
Age usually below 60 years,
Humeral
Normal ROM,
gleno-
progressive pain, tender gleno
osteophytes,
normal x-ray
humeral
humeral joint posteriorly, crepitus,
humeral head
joint
decreased ROM
flattening,
irregular or
narrowed joint
spaces, bone
cysts
Restricted
Frozen
Spontaneous onset of pain and
Non- specific
Normal ROM of
shoulder
shoulder /
stiffness which is progressive, loss
(osteopenia may
shoulder
Adhesive
of active and passive ROM in all
be present)
capsulitis
planes - loss of internal rotation is

an early sign of motion loss, no
local tenderness, pain - at end
range and even at rest
Instability
Gleno-
Age usually below 40 years old,
Hill-sachs
No history of
humeral
history of dislocation or
deformity,
dislocation or
instability
subluxation, apprehensions sign,
anterior inferior
subluxation, no
non-traumatic generalised
glenoid
apprehension
ligamentous laxity,
calcification
sign (in traumatic
repetitive stress (external rotation
(X-Ray may be
cause), no
in abduction and elevation),
normal).
impingement (in
Sulcus Sign may be possible.
non traumatic).
Reference: American Academy of Orthopedic Vurgeonia, Department of Research and scientific

affairs, shoulder pain phase 1, version 2.0-2001.
Red Flag:
7.
Age below 20 years old and above 60 years old.
Persistent pain and sleep disturbance.
Systemic signs and symptoms.
Swollen shoulder joint (non traumatic).
Caution (refer back to medical officer)
DIFFERENTIAL DIAGNOSIS IN SHOULDER PATHOGENESIS
MUSCLE:
History:
Unaccustomed activity
Repetitive eccentric activity
Direct, blunt trauma to muscle
Physical Examination:
Pain with contraction of involved muscle
Muscle imbalances of length and strength
Tenderness with palpation over involved muscle belly or trigger

points
TENDON:
History:
Blunt trauma to tendon area
Recent repetitive activity
Pain with end range and repetitive contractions
Weakness with moderate major pathology
Associated biomechanical and ergonomic deficiencies
BURSA:
History
Recent unaccustomed overuse
Recent unaccustomed weight bearing pressure
Pain with all motions
Symptoms reproduction with palpation
Pain with both AROM and PROM
CAPSULE:
History
Pain with movement worse in one particular direction
Pain at end ROM
ROM limitation in pattern characteristic to the particular joint
LIGAMENT:
History:
Trauma
If acute swelling, pain with movement that puts strain on partial

tear
If complete tear instability and giving away
Postural strain pain with prolonged static postures eases with

change in position or movement
If acute sprain swelling, compensatory muscle spasm
If partial tear pain with ligamentous integrity test
If complete tear laxity with ligamentous integrity test
If postural strain pain with prolonged overpressure in direction of

strain, pain eases with release of pressure or movement in
opposite direction
NERVE ENTRAPEMENT
History:
Paresthesias,
narrow band of sharp pain
Cord like pulling sensation
Postural adoption to reduce entrapment
Symptoms reproduced with neural tension
Possible sensory loss
DURAL STRUCTURES:
History:
Paraesthesias with prolonged sitting or flexed positions
Diffuse multiple areas of symptoms with headaches
Autonomic system symptoms
Reproduction of symptoms with slump
Associated changes in the cervical spine
HARD TISSUES: - BONE
History:
Significant history of trauma
Pain in location unusual for a soft tissue sprain or strain
Bony deformity if displaced
Grating sensations with movement
Point tenderness over fracture site
Must be counter checked with x-ray
ARTICULAR CARTILAGE:
8.
History:
Gradual onset of pain and stiffness
Progressive decline in function
Pain with end range stress to joint (mild cases)
Pain with mid-range (severe cases)
Strength and muscle imbalance deficits
Biomechanical abnormalities
ASSESSMENT
Detailed assessment should be carried out and documented in: Physio/AX.9/2000 form
(Peripheral Joint Assessment Form)
8.1 Subjective
- Identify the onset of the complaints, taking details of:
Is the shoulder pain a result of activities, traumatic events or chronic
repetitive overuse
Identify which category of shoulder pain the patients falls into e.g.
adhesive capsulitis.
The development and course of the complaints
Evaluate the course of the condition over time, taking details of the present:
severity and nature of complaints (impairments, disabilities and participation
problems)
Previous diagnostic procedures and treatment interventions and their results
Note additional information on co-morbid conditions
Current treatment: medication, other treatment or advice, and medical aids
Work-related factors that affects patients complaint.
Pain
Intensity of pain using visual analog scale (VAS)
Localised/ radiating
Nature eg.
Dull aching (muscle)
Sharp pain & shooting (nerve)
Numbness/ paraesthesia (nerve)
Deep nagging, dull (bone)
Sharp, severe, intolerable (fracture)
Throbbing, diffuse (vascular)
Area of pain, note in the body chart
Aggravating factor
Movements/activities that increase pain
Easing factor
What patient does to reduce the pain
24 hours behaviors
Mechanical * - pain towards evening or some time after activity
Inflammatory * - night pain, pain on waking up in morning
Irritability ( Low / Medium / High )
8.2 Objective
General observation
It is important to observe the shoulder complex first and then proceed to
observing the other key skeletal platforms (foot, pelvis, scapula, thoracic, upper
cervical spine/AO and system of linkages) of the body. Shoulder pain is also
known to be the result of form/force issues of the pelvic girdle. (Diane Lee, 2004).
Refer to supplementary notes.
Shoulder complex :
Contour of shoulder girdle
Position of scapulae
Position of arm
Muscle development / wasting
Alteration in skin colour / sweating etc
Physiological movement (Active, passive, overpressure)
Range of movement
Quality of movement
Reproduction of symptoms
Scapulae-humeral rhythm
End-feel
Asymmetry compared to other side
10
N.B. Isolated atrophy of:
Supraspinatus and Infraspinatus Fossa- possible rotator cuff lesion,

entrapment or injury to the suprascapular nerve, disuse)
Deltoid or Teres Minor - possible axillary nerve injury
Winging of scapular - possible long thoracic nerve injury
Popeye bulge of biceps worsened with flexion of elbow (evidence of

proximal tear of long head of biceps)
Deformity of AC joint grade 2 or 3 ( AC joint separation )
Passive Accessory movement
Anterior-posterior Glide
Posterior anterior glide
Inferior Glide
Lateral Glide
Stability Test
Anterior Drawer
Posterior Drawer
Apprehension Test
Below is further assessment that is required to be done in order for the

practitioner to get a bigger picture of the problem.
Static and dynamic situation / posture:
Standing posture
Foot Mechanics
Pelvic alignment
11
Gait
Lumbo / Pelvic Rhythm
Scapulo / Thoracic Rhythm
Thoracic Rotation
Cervical Rhythm
8.3 Palpation
Start from cervical, sternoclavicular (SC) joint and proximal clavicle and over entire
shoulder complex:
-
Temperature
Muscle spasm
Soft tissue thickening, tightness, swelling
Tenderness (anterior shoulder tenderness is a common and non specific finding)
Bony anomalies / Prominence
8.4 Neuromuscular Examination

-
Muscle Power
Sensory
Reflexes
ULTT as a screening test to exclude cervical involvement.(Refer Appendix B)
8.5 Special Tests

Below are the special tests recommended to be performed to identify the structures
which could be contributing to the symptoms. This will enable the practitioner to confirm
the findings of the initial assessment.
For further understanding of the special tests please refer to appendix B.
Take note : only relevant special test should be performed based on your subjective and
objective assessment.
12
Bil
Special tests
Structure to be tested
Outcome / response
1.
Supraspinatus test
Supraspinatus muscle
Pain and weakness
2.
Drop arm test
Rotator cuff muscle
Unable to sustain
position
3.
Speeds test
Long head of bicep
Pain
Pain in the bicipital

groove and weakness of
muscle
Tenderness in the
bicipital groove
4.
Hawkins impingement test
Impingement of rotator
cuff at acromio arch
6.
7.
Passive cross- chest adduction test
Posterior Apprehension Test
Anterior Drawer Test
Pain at subacromial
space
Express apprehension
Acromion clavicular joint
Pain at acromion
Subarachnoid bursitis
clavicular joint
Humeral head
Pain
Instability
Anterior Capsule
Instability and pain
Anterior Glenohumeral
Instability and pain
joint
8.
9.
Posterior Drawer Test
Upper Limb Tension Test 1
Posterior capsule
Median Nerve Bias
(Median Nerve Bias)

10
Upper Limb Tension Test 2B
Pain and numbness

(Dermatomal pattern)
Radial Nerve basis
Pain and numbness

(Dermatomal pattern)
11
Upper Limb Tension Test 3
Ulnar Nerve Basis
Pain and numbness

(dermatomal pattern)
13
8.6 Level of impairment and Disability (Functional Disability)

Using DASH DISABILITY / SYMPTOM SCORE - Appendix I
9.
GOALS OF TREATMENT
Plan and prioritise intervention according to assessment and patients condition.
Goal must be related to function, be measureable and set against a reasonable
time frame.
i.
Educate patient / create awareness of his condition.
ii. Decrease pain and inflammation

iii. Restore Range of motion
iv. Increase Strength
v. Restore Proprioception
vi. Restore Neuromuscular control and functions
vii. To increase patients confidence to cope adequately / Return to work
viii. Give guidance on gradual return to normal activities / Return to work.
10.
INTERVENTION
( i ) Acute pain
Rest sling /aids (48 to 72 hours ) if necessary
Electrotherapy modalities - Ice therapy , Tens , Inferential therapy (IT)
Therapeutic Exercise ( to be done within limits of pain )

- Isometric exercises
- Assisted active/ auto assisted.
- Passive movement if indicated
- Passive stretching
- Pendular / Codmans exercise
Advice e.g avoid activities that aggravate the pain and modify working activities
Deep breathing exercise / Breathing retraining

14
10.
INTERVENTION
( ii ) Sub Acute Pain

As pain reduces, close chain exercises must be done to facilitate coordination of both
agonist and antagonist muscle work.
Strengthening of scapula stabilizers is very important in early rehabilitation starting with
close chain exercises and advancing to open chain active free to open chain with weight
exercise.
Muscles to be strengthened are supraspinatus, infraspinatus, subscapularis, teres minor,
trapezius (upper, middle, inferior), deltoid, rhomboid and serratus anterior.
Proprioceptive exercises are to be included in the regime of exercise.
Emphasis is on gradual return to functional activities according to patients needs,
especially encourage activities above shoulder level e.g reaching object.
As recovery continues and more motion is gained more aggressive open chain
strengthening exercise can be included.
N.B
Scapula plane position (scaption) applied in all exercises involving shoulder
mobility and functional activity.

i.
30 45 deg forward to frontal plane..
ii.
Arc of motion more in line with the glenoid fossa of scapula.( centres humeral
head in the glenoid fossa centration )
iii.
Minimal stress on joint capsule.
Iv. Most functional activity occurs in this position
( iii ) Posture Training

Advice patient on good posture. Avoid slouched posture while in sitting or standing. A
slouched posture reduces the subacromion space and may induce a soft tissue
impingement (Solem-Bertoft E, Thoumas KA, Westerberg C-E, 1993)
15
10.
( iv )
INTERVENTION
Hydrotherapy
Hydrotherapy may be defined as the use of water, in any of its forms, to relax, assist
/resist movement and to strengthen muscles.
The techniques that can be used are:
- Bad Ragaz
- Hallawick technique
- Ai Chi
- Proprioceptive Neuromuscular Facilitation (PNF)
( v ) Myofacial Release (MFR)

Fascia tightens with inflammation of soft tissue and heals slowly ( because of a poor
blood supply), and is a pain focus ( because of its overabundant nerve
supply).Myofascial release (MFR), a hand-on technique that applies prolonged light
pressure with specific directions into the fascia system, may be used as an adjunct to
almost any treatment prescribed for the patient.
(Further reading is needed for more information.)
( vi ) Muscle energy techniques (MET)

Use of various techniques to:
lengthen a shortened, contractured or spastic muscle
strengthen a physiologically weakened muscle or group of muscles
reduce localized edema,
relieve passive congestion, and
mobilize an articulation with restricted mobility.
16
10.1
INTERVENTION
The following are recommended interventions for the respective shoulder

conditions :
Frozen Shoulder
-
Joint Mobilisation eg Gleno humeral joint
Thoracoscapular articulation mobilization
Myofacial Release (MFR)
Muscle Energy Technique (MET)
Impingement syndrome
-
Control of swelling and inflammation during acute stage
Scapular Stabilization Exercises
Posture Correction Exercise
Correction of faulty component of movements eg. Abduction of arm with

internal rotation
Acute Shoulder Dislocation / Suspected Rotator Cuff tear / Labrum tear

-
Reduce pain
Control inflammation
Restore scapula mobility and stability
Maintain ROM to uninjured joints.
Strengthening exercise begin with close kinetic chain exercise and then
progress accordingly to open chain kinetic exercise
Uni / Multi Directional Instabilities.
- Dynamic Scapula Stabilization Exercise - Refer Appendix E
N.B. Core Stabilization Exercise ( refer to Appendix G)

These are a set of exercises which may be applicable to all the above shoulder
conditions
17
10.2
RE EVALUATION
Re assess patient for progress:
(i) If patients symptoms improve, progress with rehabilitation programme.
(ii) A discharge care plan has to be formulated before discharging the patient.
(iii) If patient condition is not showing sign of improvement, change intervention /
approach of treatment or refer back to doctor.
11.
DISCHARGE CARE PLAN

( i ) Criteria for discharge
a) DASH (Disability Assessments Shoulder Hand),
Score 30 and below (Minimal Disability)
b) Visual Analog Pain Scale (VAS) . VAS score of 2 or less
c) Pain free Joint Range Of Motion (ROM) (Bailey TR, et. al 2000)
o
No impingement symptom
Joint flexibility to within functional / normal limit
( ii ) Home programme
a) Patient education - Refer to Appendix H
b) Exercises To perform exercises as instructed

c) Discharge care plan ready to be given to patient before discharge
18
12 SUPPLEMENTARY NOTES
THE FOLLOWING EXPLAINS THE ROLE OF PELVIC GIRDLE IN MANAGEMENT OF
SHOULDER PAIN
The body is a series of skeletal platform and linkages supported by muscles and
controlled by the nervous system. Movement of the shoulder is not an isolated event;
rather it is just one component of many events that happen throughout the
musculoskeletal system as motion flows along the kinetic chain. Evidence suggests just
prior to the initiation of movement, a number of deep muscles activate and produce force
closure to stabilize craniocervical junction, along with the pelvic and lumbar spine.
The pelvis is the key in most musculoskeletal dysfunctions. It is the main link in chains
(anterior and posterior oblique chains muscle) and important aspect of stability and force
transmission.
A majority of musculoskeletal dysfunction is the result of cummulative micro trauma
caused by impairments in alignment, in stabilization and in movement patterns of the
skeletal system.
Movement is based on an interaction of structure and function. Integrated model of
optimal kinesiologic function (Lee and Vleeming 2002) requires all the below
components :
Form closure: which comprises of bone, joint and ligaments.
Force closure: refers to optimal muscle function. ( global and local )
Motor control : refers to coordinated muscle activity.
Emotional and awareness
Force closure consists of the following muscles which preset (local system) before
shoulder movement take place: Transversus Abdominus, Multifidus, Pelvic Floor,
Diaphram, Deep Neck Flexors, Subscapularis, and Upper Trapezius. These key muscles
activate to SET and STABILIZE the skeleton 30 60 milliseconds before movement.
This stabilization is referred to as FORCE CLOSURE. Insufficiency in this system leads
to shoulder pain syndrome.
19
A number of tests have been deviced to test the stabilization of form and force closure at
the sacroiliac joint. The following are the tests: Standing Hip Flexion
(Stork / Gilllets), Active Straight Leg Raise Test, and Prone Hip Extension Test.
Impairment / dysfunction detected in the pelvic girdle should be addressed for optimal
outcome in the management of shoulder pain syndrome.
SACROILIAC JOINT STABILIZATION TEST

Bil
1.
Special test
Standing Hip Flexion Test
Structure to be tested
Sacroiliac Joint / pelvis girdle
Outcome / response
- Movement of ilium in relation
to sacrum /vice versa
-
PSIS move downward and

medially on the side of hip
flexion
Hypomobility of sacroiliac joint
No movement or superior
movement of sacrum relative to
PSIS
2.
Prone Lying Hip
Sacroiliac joint stabilization
Extension Test
Muscle activation sequence

(posterior oblique)
Overactivation of latissimus
dorsi
Initiation of movement at the

shoulder girdle muscles
3.
Active Straight Leg raise
Lumbo-pelvic stabilizers
Activation of local and global

muscle system
No movement in the
lumbopelvic complex
No deviation of the navel
Effort difference between the

left and right leg
rd
For further information please refer to book The Pelvic Girdle by Diane Lee, 3 Edition, 2004,
Neuromusculoskeletal Examination and Assessment by Nicole J Petty and Ann P Moore, 3rd
Edition, 2006
20
13. ALGORITHM
MANAGEMENT OF SHOULDER PAIN
Referral
Assessment of
Shoulder
Any
Red Flag?
Diagnostic Triage
1. Acute pain/ acute
shoulder dislocation
2. Impingement
3. Frozen Shoulder
4. Instabilities
Table of red flags:

Tumours
Infection
Acute trauma
Fracture and dislocation
Referred pain ( from spine,
chest, abdomen)
Yes
No
PT Intervention
Refer to Doctor
Re-evaluation
Any
Improvement?
No
Yes
Discharge Care Plan
Discharge
21
14.
REFERENCES
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impingement of the shoulder in freestyle swimmers. J Orthop Sports Phys Ther;
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Vol 17, Issue 1, 33-56
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and elbow overuse syndrome; Orthopedic Physical Therapy Home Study Course.
La Crose Wis: orthopedic Section of the American Physical Therapy Assoc;
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testing of patients with rotator cuff ( RTC ) impingement syndromes demonstrate
specific RTC external rotators power deficits. Abstract. Phys. Ther.; 77 : S 105.
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indicators of outcome; Archies of Physical Medicine and Rehabilitation. Vol 85,
Issue 8, 1231-1235
10. Green S, Buchbinder R, Hetrick S, 2005. Physiotherapy interventions for
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Med.; 8: 151-158.
12. Horseley I, 2005; Assessment of Shoulder with pain of a non-traumatic origin.
Physical Therapy in Sport, Vol 6, Issue 1, pg 6-1
13. Itoi E,Kido T,Sano A, et al. 1999; Which is more useful, the full can test or the
empty can test in detecting the torn supraspinatus tendon ? Am J Sports Med.;
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Guidelines and Practice (Abstract); Orthop. Clin. North Am. Jul., 32(3)
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Medicine, Vol 118, Issue 5, pg 452-455
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scapular muscle during a shoulder rehabilitation program. Am J Sports Med; 20:
128-134.
22
17. Patrick J. McMahon, MD; Robert E. Salis, MD (1999) Post Grauate Medicine,
Vol 106/ No. 7
18. Sherman SC, OConnor M, 2005; An Unusual Cause of Shoulder Pain: Winged
Scapular; Journal of Emergency Medicine, Vol 28, pg 329-331
19. Solem-Bertoft E, Thoumas KA, Westerberg C-E, 1993
20. Solem- Bertot E, Thomas K-A, Westerberg C-E. 1993; The influence of scapular
retration and protraction on the width of the subacromial space: An MRI study
Clin. Orthop..; 296: 99 103
21. Towsend H, Jobe FW, Pink M PerryJ. 1991; Electromyographic anylisis of the
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the lumbopelvic hip region Churchill livingstone third edition
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Assessment, a handbook for therapist.Churchill Livingstone 2001 2nd edition
.
23
15.
GLOSSARY
1. Close Kinetic Chain exercises To any exercise in which the limb is restrained against an immobile object
e.g. the ground.
2. Co-morbid Associated diseases
3. Disability Inability to perform an activity in the manner or to the extent considered normal
to that person such as problem in maintaining sitting position, picking object
from the floor and standing up from lying position.
4. Hill Sach Deformity Indentation or groove on posterolateral aspect humeral head probably due to
compression of humeral head on posterior tip of glenoid. May occur after one
episode of shoulder dislocation.
5. Little league shoulder Repetitive force applied to the open proximal humeral epiphysis which causes
accelerated growth with widening, demineralization and apparent
fragmentation of the epiphysis. Probably caused by an epiphyseal
microfracture.
6.
Lysis The destruction of cells through damage or rapture of the plasma membrane,
allowing escape of the cells contents.
7. Neuralgic amyotrophy (Parsonate-Turner Syndrome)

Characterized by severe pain across the shoulder and upper arm followed by
atrophic paralysis in muscles around the shoulder.
8.
Open Kinetic Chain exercises The distal end of the extremity is not fixed, allowing the joint to function
independently without necessarily causing motion at another joint.
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9. Osteochondromatolis A disorder of a joint featuring a change of a normal joint lining (Synovium)

tissues cellular structure to form bone cartilage tissue.
10. Osteopenia A condition of bone in which decreased calcification, decreased density, or
reduced mass occurs.
11. Pancoasts tumour A type of tumour in the lungs.
12. Sclerosis Hardening of tissue usually due to scarring (fibrosis) after inflammation or to
ageing.
13. Sulcus sign Apperance of a transverse sulcus (divot) between the humeral head and
acromion when the arm is pulled longitudinally. A sign of inferior laxity or
multidirectional instability (MDI) of the shoulder.
14. Weight lifters osteolysis
Chronic compressive forces placed on the joint with weight lifting, both on
the job and in recreational exercise programmes can cause progressive
deterioration of the joint.
25
16.
APPENDIX HEADINGS
A
Special test
C Testing for muscle weakness

D
Passive movements and active exercises
Dynamic scapula stabilisation exercises
Functional shoulder exercises
Stabilization exercises
Patient Education
DASH disability/ symptom score
26
Appendix A
Rotator cuff or biceps tendon

Strain
Tendinitis
Tear
Glenohumeral (GH) instability

Anterior
Posterior
Multidirectional
GH instability with secondary impingement
Primary impingement of the cuff of biceps tendon
Calcified tendinitis
AC joint pathology
Athritis
Separation
Weight lifters osteolysis
GH arthritis
Rheumathoid arthritis
Septic arthritis
Inflammatory arthritis
Neuropathic (Charcot) arthritis
Crystaline arthritis (gout, pseudogout )
Haemophilic arthritis
Osteochondromatosis
Thoracic outlet syndrome
Cervical spine/ root/ brachial plexus injury with referred pain
27
Suprascapular nerve neuropathy
Shoulder dislocation
Acute
Chronic (missed)
Scapuloclavicular injury
Adhesive capsulitis (Frozen shoulder)
SLAP lesion (superior labrum from anterior to posterior)
Fracture
Humerus
Clavicle
Scapula
Scapular winging
Little league shoulder
Reflex sympathetic dystrophy
Thoracic spine dysfunction
Pelvic dysfunction
Foot mechanic dysfunction
Tumour
Metastatic
Primary
Multiple myeloma
Soft tissue neoplasm
Bone disorders
Osteonecrosis Arterial Vascular Necrosis (AVN)
Paget s disease
Osteomalacia
Hyperparathyroid disease
28
Infection
Intrathoracic disorders (referred pain)

Pancoasts tumour
Diaphragmatic irritation, Esophagitis
Myocardial infarction
Psychogenic disorders
Polymyalgia rheumatica
Neuralgic amyotrophy (Parsonage Turner syndrome)
Abdominal disorders (referred pain )

Gastric ulcer
Gall bladder
Subphrenic abscess
Fibromyalgia
29
Appendix B
SPECIAL TEST
Supraspinatus test
The patients arms are brought into 90 of forward flexion and then into
30 of horizontal abduction
The arms are then internally rotated so the thumb are pointed
downward.
The therapist applies downward pressure while the patient resists and a
positive response is if there is pain / weakness, indicating
supraspinatius involvement.
Drop arm test - also a test for rotator cuff tear (especially the
supraspinatus)
The therapist passively abducts the arm to about 90 and then has the
patient to slowly lower the arm to their side.
A positive test is if the patient is unable to lower arm or is able to do so
with considerable pain and shoulder hiking.
Another possible result is he is unable to actively lower the arm but is
able to hold it at shoulder height, if the therapist gives a light tap on the
wrist the arm will fall.
Speed test (Bicep long head) the therapist resist forward flexion with
the arm in supination and the elbow completely extended.
Pain and weakness in the bicipital groove indicates a bicep strain or
bicipital tendinitis.
Hawkins Impingement sign the arm is flexed forward to 90

passively, the proximal humerus is internally rotated with the elbow
bend and a positive sign is if the patient complaints of reproducible pain
at the subacromial space. An alternative method is to forward flex the
arm to its overhead end-range and then forcibly put over pressure to the
arm trying to jam the greater tuberosity into the acromion. It is
indicates coracoacromial arch impingement at the rotator cuff.
30
Passive Cross-chest Adduction test The arm is brought to 90 of

forward flexion. With subjects trunk stabilized by therapists hand on
the posterior aspect of shoulder, grasp elbow and maximally
horizontally adduct the shoulder.
Superior shoulder pain is indicative of AC joint pathology
Anterior pain is indicative of subscapularis, supraspinatus

and/or biceps long head pathology
Posterior shoulder pain is indicative of infraspinatus, teres

minor and/or posterior capsule pathology.
Anterior Drawer (To test right shoulder)

The patient is examined supine, with the therapist standing at the
affected shoulder. The right hand of the patient is held under the
therapists axilla, clamped against the side. The shoulder is held in 80
to 120 of abduction, 0 to 20 of flexion and 0 to 30 of lateral rotation.
The therapist holds the patients scapula with his left hand while
grasping the patients upper arm and draws the humeral head anteriorly
with his right hand.
Posterior Drawer
The patient is supine. The therapist grasps the subjects elbow with one
hand and stabilizes the ipsilateral and involved shoulder with the other
hand. The subjects involved shoulder is placed in a position of 90
flexion and internal rotation, while applying a posterior force through the
long axis of the humerus.
In a positive test the patient either looks or expresses feeling of
apprehension towards further movement in the posterior direction.
The therapist also notes any posterior movement of the humeral head.
Increased posterior instability of the humeral head relative to the
scapula/glenoid fossa may be indicative of posterior instability.
31
Appendix B
ADVERSE NEURAL TENSION TEST ULTT

ULTT 1 (Median Nerve Bias)
Starting Supine lying with no pillow.
Therapist stands by the head side facing the patients feet.
Technique
Ensure constant stabilization of shoulder girdle with left hand,

with right hand holding the wrist and hand of patient.
Abduct arm to approximately 110 degrees, just below coronal

plane
Add forearm supination
Add wrist and finger extension
Add glenohumeral external rotation
Add elbow extension
Implications: Stress on the anterior interroseous nerve or median nerve

C5, C6, and C7
ULTT 2B (Radial nerve bias)

USES:
This variation may be used when the subjective assessment indicates
symptoms with a radial nerve bias.
PATIENT:
Lying diagonally supine with shoulder joint off the edge and arm in
abduction to clear bed.
PHYSIOTHERAPIST:
-
Facing patients feet with closest thigh controlling the scapular

depression and protraction.
Arms crossed so one hand holds the wrist and the other the
elbow.
Technique:
depress and protract shoulder using thigh
add elbow extension
add internal rotation of whole arm
pronate forearm
add wrist and finger flexion
add further adduction of forearm
Implications: Stress on the anterior radial nerve.
32
ULTT3 (Ulnar nerve bias):

USES:
This variation may be used when the subjective assessment indicates
symptoms with an ulnar nerve bias (medial elbow pain, symptoms
ulnar border hand, low cervical problem, C8 nerve root.
PATIENT:
Supine lying with no pillow.
PHYSIOTHERAPIST:
Facing the patient in stride standing, one hand over the patients hand,
the other hand is on the patients shoulder.
Technique:
wrist and finger extension
forearm pronation
Elbow flexion.
shoulder girdle depression
shoulder lateral rotation
shoulder abduction until hand over ear
Implications: Stress on the ulnar nerve, nerve roots C8 and T1.
SACRO ILIAC JOINT STABILIZATION TESTS
Standing Hip Flexion ( Gillet test)

The subject stands with sacroiliac joint (SIJ) exposed.
The therapist is behind the subject with the thumbs over the
PSISpines.
Note if the PSISpines are level.
If not level it indicates that the SI joint are asymmetrical, indicating
fixation on one side.
The therapist than places one thumb on the PSIS on the right side and
the other thumb over the S2 spinous process.
The subject is asked to flex his right hip actively to 90 with knee bent
to 90.
The thumb over the PSIS should move inferiorly.
If there is no change or the thumb moves superiorly, it indicates a
fixation or hypomobility.
Repeat the same on the other side.
33
Prone hip extension test

The patient lying prone is asked to lift one leg at the hip. The activity of
the contralateral latismus dorsi is observed. If there is improper
closure at the sacroiliac joint the contralateral latisimus dorsi attempts
to stabilize the lower spine. This demonstrates the link between force
closure at the sacroiliac joint and shoulder function.
Active Straight Leg Raising test

The supine patient is asked to lift the extended leg off the table, the
compensation strategies at lumbo-pelvic hip region is noted. .Effort
difference between the left and right leg (does one leg seem heavier or
harder to lift?) is also noted .The strategies used to stabilize the thorax,
the lower back and the pelvis during the task is observed .The leg
should flex at the hip joint and the pelvis should not rotate laterally or
tilt anteriorly or posteriorly relative to the lumbar spine. Proper
activation of the muscles (both in the local and global system) is
required for optimal function for the leg to rise effortlessly from the
table.
The application of compression to the pelvis reduces the effort
necessary to lift the leg for patient with pelvic pain and instability. By
varying the location of this compression during the ASLR, further
information can be gained to assist in the prescription of the exercise
to improve motor control and stability.
If the compression force make a leg lighter / effortless it is a force
closure (muscles) problem. If no change in effort check for form
closure problem.
34
Appendix C
TESTING FOR MUSCLE WEAKNESS
Lift-off the back to evaluate the subscapularis portion of the

rotator cuff.
Testing internal rotators by resisting at the wrist
The external rotators are tested for weakness by resisting

external rotation at the wrist.
35
Serratus anterior standing with shoulders flexed to 90 push

against the wall.
Inferior trapezius prone lying , arms elevated, lift both arms up

towards ceiling
Rhomboids prone lying, arms heave position, lift arms up

towards ceiling
36
Appendix D
PASSIVE MOVEMENTS AND ACTIVE EXERCISE
Internal rotation
External rotation
Elevation
Horizontal adduction / abduction
Exercises with stick
Pendular exercise
37
STRETCHING EXERCISE
Stretching Inferior capsule of shoulder and

latissimus dorsi muscle
Stretching Posterior capsule of shoulder and

posterior fibers of deltoid muscle
Stretching Anterior capsule of shoulder and

pectoralis major muscle
Stretching inferior capsule and rhomboid muscle
Stretching of levator scapulae
Stretching of the upper trapezius
38
Appendix E
Dynamic Scapula Stabilization Exercises - Muscle strengthening exercises

CLOSE KINETIC CHAIN EXERCISE
Isometric Internal Rotators
Isometric External Rotators
Isometric Flexors
Isometric Extensors
Isometric Abductors
39
CLOSE KINETIC CHAIN SCAPULA STABILIZATION
Lean forward on table
Wall Push-ups
Prone kneeling lean forward on hands, hold for 5 seconds,
Press-ups Sit on chair or table and place both

hands firmly on the sides of the chair or table,
slowly push downward on hand to elevate body
40
Appendix E
DYNAMIC SCAPULA STABILIZATION
Prone lying over ball, lean forwards on both
Prone lying over ball, lean forwards on
hands
affected arm and reach forward with the

other
Ball rolling on table

Ball rolling on wall
41
Appendix E
OPEN KINETIC CHAIN ACTIVE FREE EXERCISES
(TO IMPROVE STABILITY OF SCAPULA)
1. Prone lying , pillow under abdomen,
2. Arms at 90 deg. , thumbs to ceiling
forehead resting on towel, arms at side,
(ext. rotation), lift towards ceiling
lift towards ceiling, hold 3-5 seconds
hold for 3-5 seconds
3. Arms at 120 deg., thumbs to ceiling, lift

towards ceiling, hold for 3-5 seconds
3. Arms heave position, lift arms towards

to ceiling,hold 3-5 seconds
Exercise 1 to 4: Initially start in supine and progress to prone when there is improved scapula
control, repeat 5 times
42
Movement in PNF pattern (Flexion, abduction and external rotation)
Rowing exercise Starting position
- Ending position
*Weight or theraband may be used as a progression in this exercise
43
OPEN CHAIN STRENGTHENING EXERCISES WITH RESISTANCE
scapula retraction
overhead throwing
External rotation with resistance ( using theraband )
Internal rotation with resistance ( using theraband )
Strengthening serratus anterior with

dumbbell or water filled bottle
44
Appendix F
FUNCTIONAL EXERCISE
Reaching-forward, above head
Ball throwing in different directions
45
Appendix G
STABILIZATION EXERCISE : CORE STABILIZATION AND OBLIQUE CHAIN EXERCISES
Vojta reflex rolling dead cockroach
a). Upper limb supported in scaption position

(shoulder held in 30 abduction and forward
flextion 60)
Lower limb : hip flexion abduction and external
rotation
Tuck in chin, belly button in and elongate your
tail bone.
(with upper limb and lower limb supported)
b). Lower limb unsupported
c) Keep chin tucked in with tail bone

elongated, rotate trunk to bring alternate
elbow and knee together.
d) Rotate both legs side to side.

(cockroach with rotation)
46
VOJTA REFLEX CRAWLING MAD

ROOSTER
Principle of joint centration.
This position bring about the reflex

activation of deep neck flexor and
lower rib cage
47
Appendix H
Patients Education
Explain the nature of injury

The nature of the injury should be explained
Advise related to the individual requirement:

Sleep-positions so that the shoulder is well supported
Exercises to be performed daily and regularly through optimal range
of motion within limits of pain
If pain persists at night, apply ice pack / hot pack for 10 20 min
Avoid sudden shoulder movement during functional activities.
Avoid overly aggressive exercise regime. Do not increase exercise
duration or intensity more than 10% per week.
Work
Modify work activities if necessary. Avoid overusing your arm in an
overhead position or keep repetitive overhead to a minimum.
Do not ignore or try to work through pain.
Posture
Maintain good posture at all time.
Relaxation practice should go together with the postural training.
Other advice
Be active within limits of pain.
Rest only when joint is very painful.
Continue as much of your normal routine as possible.
48
Appendix I
DASH DISABILITY/SYMPTOM SCORE
Please rate your ability to do the following activities in the last week by circling the
number below the appropriate response.
1.
2.
3.
4.
5.
6.
7.
Open a tight or new jar

Write.
Turn a key.
Prepare a meal.
Push opens a heavy door.
Place an object on a shelf above your head
Do heavy household chores (e.g., wash
walls, wash floors).
8. Garden or do yard work.
9. Make a bed.
10. Carry a shopping bag or briefcase.
11. Carry a heavy object (over 10 lbs).
12. Change a light bulb overhead.
13. Wash or blow-dry your hair.
14. Wash your back.
15. Put on a pullover t-shirt.
16. Use a knife to cut food.
17. Recreational activities which require little
effort (e.g., card playing, knitting, etc.).
18. Recreational activities in which you take
some force or impact through your arm,
shoulder or hand (e.g., golf, hammering,
tennis, etc.).
19. Recreational activities in which you move
your arm freely (e.g., playing Frisbee,
badminton, etc.).
20. Manage transportation needs (Getting from
one place to another).
21. Sexual activities.
22. During the past week, to what extent has

your arm, shoulder or hand problem
interfered with your normal social activities
with family, friends, neighbors or groups?
(Circle number
NO
DIFFICULTY
1
1
1
1
1
1
1
MILD
DIFFICULTY
2
2
2
2
2
2
2
MODERATE
DIFFICULTY
3
3
3
3
3
3
3
SEVERE
DIFFICULTY
4
4
4
4
4
4
4
UNABLE
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
5
1
NOT AT ALL
2
SLIGHTLY
3
MODERATE
4
QUITE A BIT
5
EXTREM
ELY
NOT LIMITED
AT ALL
23. During the past week, were you limited in
your work or other regular daily activities
as a result of your arm, shoulder or hand
problem? (circle number) 1 2 3 4 5. Please
rate the severity of the following symptoms
in the last week.
24. Arm, shoulder or hand pain.

25. Arm, shoulder or hand pain when you
performed any specific activity.
26. Tingling (pins and needles) in your arm,
shoulder or hand.
SLIGHTY
LIMITED
MODERATELY
LIMITED
VERY
LIMITED
5
5
5
5
5
5
5
UNABLE
NONE
MILD
MODERATE
SEVERE
1
1
2
2
3
3
4
4
EXTREM
E
5
5
49
27. Weakness in your arm, shoulder or hand.

28. Stiffness in your arm, shoulder or hand.
1
1
NO
DIFFICULTY
2
2
MILD
DIFFICULTY
3
3
MODERATE
DIFFICULTY
4
4
SEVERE
DIFFICULTY
5
5
SO
MUCH
DIFFICUL
TY THAT
I CANT
SLEEP
STRONGLY
DISAGREE
DISAGREE
NEITHER
AGREE NOR
DISAGREE
AGREE
STRONG
LY
AGREE
29. During the past week, how much difficulty

have you had sleeping because of the pain
in your arm, shoulder or hand? (circle
number)
30. I feel less capable, less confident or less

useful because of my arm, shoulder or
hand problem. (circle number
THE ARM, SHOULDER AND HAND

DASH DISABILITY/SYMPTOM SCORE
= (Sum of n responses - 1) x 25
n
where n is equal to the number of completed responses.
A DASH score may not be calculated if there are greater than 3 missing items
Eg. If a patient responded with a score of 4 in all 30 questionaires of activities, the total
will be :
n=30
Sum of responses = 30x4

Score =
(30x4) - 1
30
x 25 = 75%
50
INTERPRETATION OF DASH DISABILITY SYMPTOM SCORE

The higher the percentage scored, the more disabilities the patient has
PERCENTAGE SCORE
LEVEL OF DISABILITIES
80 % - 100 %
Extreme Disabilities
60 % - 79 %
Severe Disabilities
40 % - 59 %
Moderate Disabilities
20 % - 39 %
Mild Disabilities
0 % - 19 %
No Disabilities
Patient can be discharged at mild or no disabilities in Dash Disability Symptom

Score, with consideration that other associated problems of neck, thoracic and
lower quadrant (lumbar, pelvis, hip and lower limb) have been addressed in the
management of shoulder problem.
51
Editors
Y. Bhg. Datin Hjh. Asiah Mohd. Hashim
Bsc (Hons) App Rehab PT UK,
Dep in PT- KKM
Cert Sports PT Uni Melb
Ketua Profesyen Fisioterapi
Pegawai Pemulihan Perubatan (Anggota ) Gred U44
Hospital Kuala Lumpur
Encik Daaljit Singh H. S.
Bsc (Hons) App Rehab PT UK,
Dip PT - KKM,
Dip Acu Colombo,
M.D.(M.A.) Colombo
Cert Councelling KKM
Cert Sports PT Uni Melb,
Jurupulih Perubatan (Anggota) Gred U38
Hospital Raja Permaisuri Bainun, Ipoh, Perak
Puan Sarkuna Devi Premnath
Dep in PT- KKM
Graduate Cert. In Applied Sc ( PT) - Uni Sydney, NSW Aus.
Hospial Tengku Ampuan Rahimah, Klang, Selangor.
Pn. Gan Pein Pein
Dep in PT- KKM
Postgrad program ( Mckenzie Inst. International )
Hospital Kuala Lumpur.
52
Contributors
Y. Bhg. Datin Hjh. Asiah Mohd. Hashim
Ketua Profesyen Fisioterapi
Encik Daaljit Singh H. S.
Hospital Raja Permaisuri Bainun, Ipoh, Perak
Puan Sarkuna Devi Pramnath
Hospial Tengku Ampuan Rahimah, Klang, Selangor
Pn. Gan Pein Pein
Pn. Hjh. Normah Abd. Jamil
Pegawai Pemulihan Perubatan (Anggota) Gred U41
Hospital Tuanku Fauziah, Kangar Perlis
Pn Yew Su Fen
Hospital Pulau Pinang, Pulau Pinang
Cik Catherine Wong Pick Yieng,
Hospital Sibu, Sarawak
En Md Yunus Sufaat
Program Fisioterapi,
Kolej Sain Kesihatan Bersekutu,
Johor Bharu Johor
Cik Se To Phui Lin
Pn Halimah bt Hashim
Hospital Raja Perempuan Zainab II
Kota Bharu, Kelantan
Pn. Jamaliah Musa
Hospital Umun Sarawak, Kucing, Sarawak
Pn. Hjh. Hanisah Mhd. Noor
Hospital Sultanah Aminah,
Johor Bharu, Johor
Pn. Ruhaya Hussien
Hospital Tuanku Jaafar, Seremban, N. Sembilan
( Retired in 2009 )
53
Pn. Mariam Mohd. Nawang

Hospital Sultanah Aminah, Johor Bharu, Johor
Pn Siti Mariah Seman
Hospital Tengku Ampuan Rahimah, Klang, Selangor
Cik Mary Tharsis
(Currently in Sunway Medical Centre)
Pn. Kanagambegai a/p Manickam
Hospital Melaka, Melaka
En. Jumat Pani
Jurupulih Perubatan (Anggota ) Gred U36
Hospital Queen Elizabeth, Kota Kinabalu, Sabah
Tuan Hj. Mat Som Ahmad
Hospital Teluk Intan, Perak
En. Rajpal singh
Hospital Pulau Pinang, Pulau Pinang
En. Hairul Hapizi Samaon
Hospital Sungai Buloh, Selangor
En. Mohd. Solihin Ali Hassan
Jurupulih Perubatan (Anggota ) Gred U29
.
54

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KEMENTERIAN KESIHATAN MALAYSIA

Physiotherapy Care Protocol

PHYSIOTHERAPY CARE PROTOCOL FOR SHOULDER PAIN

Signs and symptoms

Causes of shoulder pain

Discharge care plan

Working Committee, Physiotherapy Profession MOH February 2011

PHYSIOTHERAPY CARE PROTOCOL FOR SHOULDER PAIN

In government hospitals in Malaysia, shoulder pain is the second most common

Working Committee, Physiotherapy Profession MOH February 2011

PHYSIOTHERAPY CARE PROTOCOL FOR SHOULDER PAIN

3. SIGNS AND SYMPTOMS

Pain common symptom for all shoulder problems

Swelling and warmth

Weak / inhibited muscles

Looseness - Shoulder instability

Deformity of shoulder e.g. loss of contour, winging of scapula.

Crepitus popping / clicking could be due to cartilage or rotator cuff tear or

CAUSES OF SHOULDER PAIN (Refer to Appendix A)

PHYSIOTHERAPY CARE PROTOCOL FOR SHOULDER PAIN

Findings consistent with

Age usually over 40 years old, cuff

weakness, atrophy, tenderness,

painful arc of motion, night pain,

impingement sign, upper arm pain,

Age usually below 60 years,

progressive pain, tender gleno

humeral joint posteriorly, crepitus,

Spontaneous onset of pain and

stiffness which is progressive, loss

of active and passive ROM in all

planes - loss of internal rotation is

Age usually below 40 years old,

subluxation, apprehensions sign,

sign (in traumatic

repetitive stress (external rotation

in abduction and elevation),

Sulcus Sign may be possible.

Reference: American Academy of Orthopedic Vurgeonia, Department of Research and scientific

Working Committee, Physiotherapy Profession MOH February 2011

PHYSIOTHERAPY CARE PROTOCOL FOR SHOULDER PAIN

Age below 20 years old and above 60 years old.

Persistent pain and sleep disturbance.

Systemic signs and symptoms.

Swollen shoulder joint (non traumatic).

Caution (refer back to medical officer)

DIFFERENTIAL DIAGNOSIS IN SHOULDER PATHOGENESIS

Repetitive eccentric activity

Direct, blunt trauma to muscle

Pain with contraction of involved muscle

Muscle imbalances of length and strength

Tenderness with palpation over involved muscle belly or trigger

Blunt trauma to tendon area

Recent repetitive activity

Pain with end range and repetitive contractions

Weakness with moderate major pathology

Associated biomechanical and ergonomic deficiencies

Working Committee, Physiotherapy Profession MOH February 2011

PHYSIOTHERAPY CARE PROTOCOL FOR SHOULDER PAIN

Recent unaccustomed overuse

Recent unaccustomed weight bearing pressure

Pain with all motions