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CSP Shoulder Guidelines
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Williams Ariel Chandia PérezCopyright:
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%VIDENCE
BASED CLINICAL GUIDELINES
FOR THE DIAGNOSIS ASSESSMENT AND PHYSIOTHERAPY
MANAGEMENT OF SHOULDER IMPINGEMENT SYNDROME
!CKNOWLEDGEMENTS
4HE 'UIDELINE $EVELOPMENT 'ROUP !PPENDIX WOULD LIKE TO THANK THE FOLLOWING FOR THEIR
ASSISTANCE AND SUPPORT IN DEVELOPING THESE GUIDELINES
s
!DVISERS TO THE GUIDELINE DEVELOPMENT GROUP !PPENDIX
s
4HE LOCAL PEER REVIEW GROUP !PPENDIX
s
4HE NATIONAL PEER REVIEW GROUP !PPENDIX
s
4HE #HARTERED 3OCIETY OF 0HYSIOTHERAPY
s
0ORTSMOUTH #ITY 4EACHING 0RIMARY #ARE 4RUST 04# &AREHAM AND 'OSPORT 0#4 %AST (ANTS 0#4
s
4HE 3CHOOL OF (EALTH AND 3OCIAL #ARE 5NIVERSITY OF 4EESSIDE
s
4EESSIDE #ENTRE FOR 2EHABILITATION 3CIENCES 5NIVERSITY OF 4EESSIDE
s
#LINICAL !UDIT $EPARTMENT 0ORTSMOUTH #ITY 4EACHING 0#4
4HE 'UIDELINE $EVELOPMENT 'ROUP ARE ALSO GRATEFUL TO +ATE $AVIES #HARLOTTE 'RAY 3UZANNE (ARRADINE
,ISA (ARVEY #ATHERINE 0OLLITT 3UE 3CREATON AND "ELINDA 4REWBY FOR THEIR VALUED CONTRIBUTIONS
4HIS DOCUMENT SHOULD BE CITED AS FOLLOWS
(ANCHARD . #UMMINS * AND *EFFRIES # %VIDENCE
BASED CLINICAL GUIDELINES FOR THE DIAGNOSIS ASSESSMENT AND
PHYSIOTHERAPY MANAGEMENT OF SHOULDER IMPINGEMENT SYNDROME #HARTERED 3OCIETY OF 0HYSIOTHERAPY ,ONDON 5+
4HIS CLINICAL GUIDELINE WAS ENDORSED BY THE #HARTERED 3OCIETY OF 0HYSIOTHERAPY IN *ULY
4HE ENDORSEMENT PROCESS HAS INCLUDED REVIEW BY RELEVANT EXTERNAL EXPERTS AS WELL AS PEER REVIEW
4HE RIGOUR OF THE APPRAISAL PROCESS CAN ASSURE USERS OF THE GUIDELINE THAT THE RECOMMENDATIONS FOR PRACTICE
ARE BASED ON A SYSTEMATIC PROCESS OF IDENTIFYING THE BEST AVAILABLE EVIDENCE AT THE TIME OF ENDORSEMENT
2EVIEW DATE
.IGEL (ANCHARD
*ANIS #UMMINS
#LAIRE *EFFRIES
%VIDENCE
BASED CLINICAL GUIDELINES
FOR THE DIAGNOSIS ASSESSMENT AND PHYSIOTHERAPY
MANAGEMENT OF SHOULDER IMPINGEMENT SYNDROME
4(% #(!24%2%$ 3/#)%49 /& 0(93)/4(%2!09
!CKNOWLEDGEMENTS
4HE 'UIDELINE $EVELOPMENT 'ROUP !PPENDIX WOULD LIKE TO THANK THE FOLLOWING FOR THEIR
ASSISTANCE AND SUPPORT IN DEVELOPING THESE GUIDELINES
s
!DVISERS TO THE GUIDELINE DEVELOPMENT GROUP !PPENDIX
s
4HE LOCAL PEER REVIEW GROUP !PPENDIX
s
4HE NATIONAL PEER REVIEW GROUP !PPENDIX
s
4HE #HARTERED 3OCIETY OF 0HYSIOTHERAPY
s
0ORTSMOUTH #ITY 4EACHING 0RIMARY #ARE 4RUST 04# &AREHAM AND 'OSPORT 0#4 %AST (ANTS 0#4
s
4HE 3CHOOL OF (EALTH AND 3OCIAL #ARE 5NIVERSITY OF 4EESSIDE
s
4EESSIDE #ENTRE FOR 2EHABILITATION 3CIENCES 5NIVERSITY OF 4EESSIDE
s
#LINICAL !UDIT $EPARTMENT 0ORTSMOUTH #ITY 4EACHING 0#4
4HE 'UIDELINE $EVELOPMENT 'ROUP ARE ALSO GRATEFUL TO +ATE $AVIES #HARLOTTE 'RAY 3UZANNE (ARRADINE
,ISA (ARVEY #ATHERINE 0OLLITT 3UE 3CREATON AND "ELINDA 4REWBY FOR THEIR VALUED CONTRIBUTIONS
#ONTENTS
)NTRODUCTION
7HY EVIDENCE BASED GUIDELINES FOR SHOULDER IMPINGEMENT SYNDROME
4ARGET 5SERS
!IMS
/BJECTIVES
3COPE OF THE GUIDELINES
$EVELOPMENT STRATEGY
'UIDELINE $EVELOPMENT 'ROUP
!DVISERS TO THE 'UIDELINE $EVELOPMENT 'ROUP
0EER REVIEW
3TAGE ONE @LOCAL PEER REVIEW
3TAGE TWO NATIONAL PEER REVIEW
3ERVICE USERS FOCUS GROUP
&UNDING
3EARCHING FOR THE EVIDENCE
,ITERATURE APPRAISAL PROCESS
%VIDENCE RELATING TO PHYSIOTHERAPY INTERVENTIONS
%VIDENCE RELATING TO DIAGNOSIS ASSESSMENT
$ISSEMINATION
)MPLEMENTATION
2EVISIONS
(EALTH BENEFITS SIDE EFFECTS AND RISKS
"ARRIERS TO IMPLEMENTATION
#OST IMPLICATIONS
!UDIT
2EFERENCES SUPPORTING 3ECTION
4HE CLINICAL QUESTION
3HOULDER IMPINGEMENT SYNDROME
$EFINITION OF SHOULDER IMPINGEMENT SYNDROME
5NDERLYING MECHANISMS
.EER 7ELSHS CLASSIFICATION
/THER TYPES OF IMPINGEMENT AT THE SHOULDER
2EFERENCES SUPPORTING 3ECTION
%VIDENCE UNDERPINNING THE DIAGNOSIS AND ASSESSMENT
OF SHOULDER IMPINGEMENT SYNDROME
3UBJECTIVE ASSESSMENT
!GE
-ODE OF ONSET
0AIN
/THER SYMPTOMS
&UNCTION
/BJECTIVE ASSESSMENT
1UANTIFYING PAIN
)NSPECTION
-USCLE BULK
#ERVICAL AND UPPER THORACIC POSTURE
3TATIC SCAPULAR POSTURE
3CAPULOHUMERAL RHYTHM
0HYSICAL TESTS
2ANGE OF MOVEMENT
)NSTABILITY
4ESTS OF CONTRACTILE FUNCTION
3PECIFIC TESTS FOR COMPLETE CUFF TEARS
3PECIFIC IMPINGEMENT TESTS
$IFFERENTIATION FROM OTHER INTRACAPSULAR CAUSES OF IMPINGEMENT
0ALPATION
2ECOMMENDATIONS FOR DIAGNOSIS AND ASSESSMENT
(ISTORY
&UNCTIONAL STATUS
0HYSICAL ASSESSMENT
)NSPECTION
0HYSICAL TESTS
2ANGE OF MOVEMENT
)NSTABILITY TESTS
#ONTRACTILE FUNCTION TESTS
)MPINGEMENT TESTS
0ALPATION
$IAGNOSTIC IMAGING
2ADIOGRAPHS
5LTRASOUND MAGNETIC RESONANCE IMAGING -2) AND MAGNETIC
2EFERENCES SUPPORTING 3ECTIONS n
RESONANCE ARTHROGRAPHY -2!
!IMS AND OBJECTIVES OF PHYSIOTHERAPY FOR SHOULDER
IMPINGEMENT SYNDROME
!IMS
/BJECTIVES
%VIDENCE UNDERPINNING THE PHYSIOTHERAPY MANAGEMENT
OF SHOULDER IMPINGEMENT SYNDROME INCLUDING SUPERIOR LABRUM
ANTERIOR TO POSTERIOR LESIONS AND POSTERIOR SUPERIOR GLENOID
IMPINGEMENT
2EDUCTION OF SUBACROMIAL INFLAMMATION AND PAIN MANAGEMENT
2EST AVOIDANCE OF AGGRAVATING ACTIVITIES AND NON STEROIDAL
ANTI INFLAMMATORY DRUGS
#OLD THERAPY
(EAT THERAPY
0ULSED ELECTROMAGNETIC FIELDS
5LTRASOUND
,ASER
4RANSCUTANEOUS ELECTRICAL NERVE STIMULATION
$EEP TRANSVERSE FRICTION MASSAGE
3TEROID INJECTION
)MPROVEMENT OF POSTURE
2ESTORATION OF RANGE STRENGTH STABILITY AND SCAPULOHUMERAL RHYTHM
2ECOMMENDATIONS FOR PHYSIOTHERAPY INTERVENTIONS IN SHOULDER
IMPINGEMENT SYNDROME INCLUDING SUPERIOR LABRUM ANTERIOR TO
POSTERIOR LESIONS AND POSTERIOR SUPERIOR GLENOID IMPINGEMENT
2EDUCTION OF SUBACROMIAL INFLAMMATION AND PAIN MANAGEMENT
2EST
.ON STEROIDAL ANTI INFLAMMATORY DRUGS
#OLD THERAPY
(EAT
0ULSED ELECTROMAGNETIC FIELDS
5LTRASOUND
,ASER 4RANSCUTANEOUS ELECTRICAL NERVE STIMULATION
$EEP TRANSVERSE FRICTION MASSAGE
3TEROID INJECTION
)MPROVEMENT OF POSTURE
2ESTORATION OF RANGE STRENGTH STABILITY AND SCAPULOHUMERAL RHYTHM
2EFERENCES SUPPORTING 3ECTIONS n
7HEN TO REFER FOR AN ORTHOPAEDIC OPINION
2EFERENCES SUPPORTING 3ECTION
!PPENDICES
!PPENDIX
'UIDELINE DEVELOPMENT GROUP
!PPENDIX
!DVISERS TO THE 'UIDELINE $EVELOPMENT 'ROUP
!PPENDIX
,OCAL PEER REVIEW
!PPENDIX
.ATIONAL PEER REVIEW
!PPENDIX
2EVIEWERS COMMENTS AND '$' RESPONSES
!PPENDIX
#ONSULTATION WITH SERVICE USERS RESULTS
!PPENDIX
$ETAILED ELECTRONIC SEARCH STRATEGY
!PPENDIX
!RTICLE APPRAISAL SYSTEM
!PPENDIX
4ABLE OF SYSTEMATIC REVIEWS AND CRITICAL APPRAISAL OF THE PRIMARY LITERATURE
!PPENDIX 3HOULDER EXERCISES HOME PROGRAMME
!PPENDIX 3UMMARY OF EXERCISE PROTOCOLS FOR SHOULDER IMPINGEMENT SYNDROME
!PPENDIX 2ECOMMENDATIONS FOR THE PHYSIOTHERAPEUTIC MANAGEMENT OF
SHOULDER IMPINGEMENT SYNDROME FLOW CHART
)NTRODUCTION
7HY EVIDENCE
BASED CLINICAL GUIDELINES FOR SHOULDER IMPINGEMENT SYNDROME 3)3
3HOULDER PAIN ACCOUNTS FOR OVER OF GENERAL PRACTITIONER '0 CONSULTATIONS 'REEN ET AL A
AND IN DUE COURSE ACCORDING TO A $UTCH STUDY OF THESE PATIENTS ARE REFERRED FOR PHYSIOTHERAPY
,IESDECK ET AL @)MPINGEMENT PROBABLY ACCOUNTS FOR HALF OF SUCH REFERRALS $INNES ET AL
4HESE DATA HINT AT THE PROBLEM IMPINGEMENT PRESENTS ON A NATIONWIDE BASIS 4HIS IS AN AREA WHERE
EVIDENCE
BASED PRACTICE MIGHT HAVE A GREAT IMPACT BECAUSE EVIDENCE SUGGESTS THAT IMPINGEMENT DOES
RESPOND TO APPROPRIATE PHYSIOTHERAPY 'REEN ET AL A
0HYSIOTHERAPISTS HAVE A DUTY TO BASE THEIR PRACTICE ON SUCH EVIDENCE THAT IS TO SAY THE BEST AVAILABLE
$EPARTMENT OF (EALTH #HARTERED 3OCIETY OF 0HYSIOTHERAPY "UT FROM THE
PERSPECTIVE OF A BUSY CLINICIAN EVIDENCE
BASED PRACTICE MAY PROVE AN ELUSIVE STANDARD THE BODY OF
EVIDENCE MAY APPEAR SO LARGE SO VARIABLE IN QUALITY AND SO CONTRADICTORY AS TO BE OVERWHELMING 3OME
FORM OF OVERVIEW IS CLEARLY REQUIRED 4HIS NEED IS PARTLY SATISFIED BY A RECENT MAJOR SYSTEMATIC REVIEW
OF DIAGNOSTIC STUDIES $INNES ET AL AND #OCHRANE REVIEWS EG "UCHBINDER ET AL 'REEN
ET AL A B (OWEVER MANY @DIAGNOSTIC STUDIES DID NOT MEET $INNES ET ALS CRITERIA FOR
INCLUSION AND #OCHRANE REVIEWS ON THE WHOLE ARE RESTRICTED TO RANDOMISED CONTROLLED TRIALS 2#4S OF
INTERVENTIONS AND DO NOT INCORPORATE RESEARCH OF OTHER TYPES
$RAWING ON #OCHRANE REVIEWS AS THE @GOLD STANDARD OF EVIDENCE ON INTERVENTIONS AND $INNES ET ALS
SYSTEMATIC REVIEW AS THEIR DIAGNOSTIC EQUIVALENT THE PRESENT GUIDELINES INTEGRATE THIS INFORMATION
INTO ONE SOURCE USE TRANSPARENT PROCESSES TO @PLUG THE GAPS WITH EVIDENCE FROM WEAKER SOURCES AND
ENDEAVOUR TO PROVIDE PLAIN PRACTICAL AND WELL JUSTIFIED RECOMMENDATIONS
4HE CLINICAL QUESTION
4HESE GUIDELINES ADDRESS THE CLINICAL QUESTION
s
7HAT IS BEST PRACTICE IN THE PHYSIOTHERAPY DIAGNOSIS ASSESSMENT AND MANAGEMENT OF SHOULDER
IMPINGEMENT SYNDROME
4ARGET USERS
)T IS ANTICIPATED THAT THESE GUIDELINES WILL BE USED BY GENERAL PRACTITIONERS ORTHOPAEDIC SURGEONS AND
RHEUMATOLOGISTS IN ADDITION TO PHYSIOTHERAPISTS
!IMS
s
4O FACILITATE BEST PRACTICE IN PHYSIOTHERAPISTS DIAGNOSIS ASSESSMENT AND MANAGEMENT OF SHOULDER
IMPINGEMENT SYNDROME AND RELATED PROFESSIONALS AWARENESS OF SUCH PRACTICE
s
4O STANDARDISE PHYSIOTHERAPISTS DIAGNOSIS ASSESSMENT AND MANAGEMENT OF SHOULDER IMPINGEMENT
SYNDROME
/BJECTIVES
s
4O IDENTIFY AND CRITICALLY APPRAISE THE BEST AVAILABLE EVIDENCE RELATING TO THE ASSESSMENT AND DIAGNOSIS
OF SHOULDER IMPINGEMENT SYNDROME
s
4O IDENTIFY AND SYSTEMATICALLY APPRAISE THE BEST AVAILABLE EVIDENCE RELATING TO THE PHYSIOTHERAPY
MANAGEMENT OF SHOULDER IMPINGEMENT SYNDROME
s
4O MAKE RECOMMENDATIONS DERIVED BY TRANSPARENT PROCESSES FROM THE BEST AVAILABLE EVIDENCE FOR THE
ASSESSMENT AND DIAGNOSIS OF SHOULDER IMPINGEMENT SYNDROME
s
4O MAKE GRADED RECOMMENDATIONS AGAIN DERIVED BY TRANSPARENT PROCESSES FROM THE BEST AVAILABLE
EVIDENCE FOR THE PHYSIOTHERAPY MANAGEMENT OF SHOULDER IMPINGEMENT SYNDROME
s
4O HIGHLIGHT AREAS WHERE FURTHER RESEARCH IS REQUIRED
3COPE OF THE GUIDELINES
4HESE GUIDELINES ARE INTENDED TO APPLY TO SHOULDER IMPINGEMENT SYNDROME IN ADULTS AGED AND OVER
IRRESPECTIVE OF THEIR GENDER OR RACE 4HEY MAY BE UTILISED TO INFORM ALL STAGES OF THE NON
OPERATIVE OR PRE
OPERATIVE CARE PATHWAY NAMELY
s
)NITIAL ASSESSMENTDIAGNOSIS
s
0HYSIOTHERAPY MANAGEMENT
s
%VALUATION OF OUTCOME
s
0ATIENT DISCHARGE TO SELF MANAGEMENT
s
2EFERRAL FOR ORTHOPAEDIC OPINION IF REQUIRED
4HEY SPECIFICALLY DO NOT APPLY TO
s
0AIN FROM CAUSES OTHER THAN SHOULDER IMPINGEMENT SYNDROME
s
)MPINGEMENT IN THE HEMIPLEGIC SHOULDER
s
!LTERNATIVE THERAPIES FOR THIS PURPOSE ACUPUNCTURE IS CONSIDERED AN ALTERNATIVE THERAPY
s
0ERI OR POST OPERATIVE MANAGEMENT
$EVELOPMENT STRATEGY
'UIDELINE $EVELOPMENT 'ROUP '$'
4HE GUIDELINES WERE DEVELOPED BY A CORE GROUP OF CLINICAL AND ACADEMIC PHYSIOTHERAPISTS EACH WITH A
SPECIAL INTEREST IN THE SHOULDER !PPENDIX
#ONFLICT OF INTEREST .IGEL (ANCHARD IS A &ELLOW AND SENIOR LECTURER OF THE #YRIAX /RGANISATION .O OTHER
POTENTIAL CONFLICTS OF INTEREST WERE DECLARED
!DVISERS TO THE '$'
4HE '$' WAS SUPPORTED BY A NUMBER OF ADVISERS DRAWN FROM AMONG SENIOR ACADEMIC AND CLINICAL
PHYSIOTHERAPISTS !PPENDIX
0EER REVIEW
0RIOR TO #30 ENDORSEMENT THE GUIDELINES UNDERWENT A TWO
STAGE QUALITY ASSURANCE PROCESS COMPRISING
A @LOCAL AND THEN A NATIONAL REVIEW 2EVIEWERS WERE BRIEFED TO CRITICALLY COMMENT ON
s
4HE OVERALL DEVELOPMENT STRATEGY
s
4HE VALIDITY OF THE RECOMMENDATIONS
s
4HE CLINICAL RELEVANCE OF THE GUIDELINES AND RECOMMENDATIONS
s
4HE FORMAT LAYOUT AND PRESENTATION OF THE DOCUMENT
3TAGE ONE @LOCAL PEER REVIEW
0EERS AND MEDICAL COLLEAGUES LOCAL TO THE 0ORTSMOUTH AREA REVIEWED THE GUIDELINES DURING THEIR
DEVELOPMENT !PPENDIX AND OFFERED SUGGESTIONS FOR IMPROVEMENTS 2OTATIONAL PHYSIOTHERAPISTS STAFF
GRADE AND SENIOR )) IN MUSCULOSKELETAL OUTPATIENTS ALSO CONTRIBUTED TO THIS PROCESS AS DID FINAL YEAR
PHYSIOTHERAPY STUDENTS AT THE 5NIVERSITY OF 4EESSIDE -IDDLESBROUGH
3TAGE TWO NATIONAL PEER REVIEW
!PPROACHES TO DIAGNOSING ASSESSING AND MANAGING SHOULDER IMPINGEMENT SYNDROME ARE DIVERSE AND
THE '$' WAS KEEN TO EXPOSE THE DEVELOPING GUIDELINES TO A RANGE OF PERSPECTIVES IN ORDER THAT THEY
SHOULD BE AS REPRESENTATIVE AS POSSIBLE 7ITH THIS IN MIND REVIEW WAS INVITED FROM SELECTED LEADING
ACADEMICS AND CLINICIANS CHOSEN TO EMBODY A REPRESENTATIVE BREADTH OF OPINION IN THE FIELD AT A
NATIONAL LEVEL !PPENDIX
2EVIEWERS COMMENTS AND THE '$'S RESPONSES ARE TABULATED IN !PPENDIX
3ERVICE USERS FOCUS GROUP
3ERVICE USERS VIEWS WERE OBTAINED REGARDING THE ACCEPTABILITY OF THE RECOMMENDATIONS FROM THEIR
PERSONAL PERSPECTIVES IN A FOCUS GROUP !PPENDIX
&UNDING
4HE RESPECTIVE EMPLOYERS OF THE '$' RELEASED THE MEMBERS FOR MEETINGS AND MET ASSOCIATED TRAVEL
AND SUBSISTENCE COSTS 4HE #HARTERED 3OCIETY OF 0HYSIOTHERAPY #30 PROVIDED MEETING ROOMS WITHOUT
CHARGE AND FUNDED THE PRODUCTION OF THE FINAL DOCUMENT .O OTHER SPECIFIC INTERNAL OR EXTERNAL FUNDING
WAS PROVIDED
3EARCHING FOR THE EVIDENCE
!-%$ #).!(, %-"!3% -%$,).% 0%$RO AND 0RE-%$,).% WERE SEARCHED TO -ARCH FOR
THE FOLLOWING KEY WORDS
s
3HOULDERS
s
)NJURIESPATHOLOGY
s
2OTATOR CUFF INJURIES
s
4ENDINITIS
s
'LENOHUMERAL JOINT
s
)MPINGEMENT SYNDROME
s
3HOULDER IMPINGEMENT SYNDROME
s
3UBACROMIAL IMPINGEMENT SYNDROME
s
2EHABILITATION
s
)NSTABILITY
s
%XERCISE REHABILITATION
s
0HYSICAL THERAPY
s
#ONSERVATIVE TREATMENT
s
3HOULDER SURGERY
s
3PORTS REHABILITATION
4HE DETAILED ELECTRONIC SEARCH STRATEGY IS SHOWN IN !PPENDIX )N ADDITION MEMBERS OF THE '$'
CONDUCTED HAND SEARCHES FOR RELEVANT MATERIAL IN TEXTBOOKS AND JOURNALS NOT INCLUDED IN THE DATABASES
AND ALL LITERATURE OBTAINED WAS SCANNED FOR FURTHER REFERENCES 3EARCHES WERE LIMITED TO HUMAN STUDIES
7HERE THESE WERE LACKING THE SEARCH WAS EXTENDED TO INCLUDE ANIMAL STUDIES &OR PRACTICAL REASONS
SEARCHES WERE LIMITED TO THE %NGLISH LANGUAGE &URTHER SEARCHES WERE MADE UP TO /CTOBER FOR
NEW SYSTEMATIC REVIEWS WHICH THE '$' CONSIDERED IMPORTANT TO THE GUIDELINES
,ITERATURE APPRAISAL PROCESS
-EMBERS OF THE '$' THE ADVISERS TO THE '$' AND CLINICAL COLLEAGUES UNDERTOOK THE LITERATURE
APPRAISAL PROCESS AFTER TRAINING
%VIDENCE RELATING TO PHYSIOTHERAPY INTERVENTIONS
4HE '$' GRADED EVIDENCE RELATING TO PHYSIOTHERAPY INTERVENTIONS INCLUDING INJECTION THERAPY
ACCORDING TO #30 RECOMMENDATIONS #30 AS SET OUT IN 4ABLE
4ABLE ,EVELS OF EVIDENCE #30
,EVEL
4YPE OF EVIDENCE
)A
%VIDENCE OBTAINED FROM A SYSTEMATIC REVIEW OR RANDOMISED CONTROLLED TRIALS
)B
%VIDENCE OBTAINED FROM AT LEAST ONE RANDOMISED CONTROLLED TRIAL
)LA
%VIDENCE OBTAINED FROM AT LEAST ONE WELL DESIGNED CONTROLLED STUDY WITHOUT RANDOMISATION
)LB
%VIDENCE OBTAINED FROM AT LEAST ONE OTHER TYPE OF WELL DESIGNED QUASI EXPERIMENTAL STUDY
)))
%VIDENCE OBTAINED FROM WELL DESIGNED NON EXPERIMENTAL DESCRIPTIVE STUDIES SUCH AS
COMPARATIVE STUDIES CORRELATION STUDIES AND CASE STUDIES
)6
%VIDENCE OBTAINED FROM EXPERT COMMITTEE REPORTS OR OPINIONS ANDOR CLINICAL EXPERIENCE OF
RESPECTED AUTHORITIES
%IGHT RELEVANT SYSTEMATIC REVIEWS WERE IDENTIFIED ALL OF WHICH WERE UTILISED IN THE PRESENT GUIDELINES
4HESE WERE )NTERVENTIONS FOR SHOULDER PAIN 'REEN ET AL A #ORTICOSTEROID INJECTIONS FOR SHOULDER
PAIN "UCHBINDER ET AL 0HYSIOTHERAPY INTERVENTIONS FOR SHOULDER PAIN 'REEN ET AL B
AND $EEP TRANSVERSE FRICTION MASSAGE FOR TREATING TENDINITIS "ROSSEAU ET AL 4HESE FOUR ARE ALL
#OCHRANE REVIEWS WHICH WHERE APPROPRIATE SUBJECT EXISTING DATA TO META
ANALYSIS AND WHICH MAY
BE CONSIDERED A @GOLD STANDARD OF 'RADE A EVIDENCE "-* #LINICAL %VIDENCE 3PEED AND (AZLEMAN
WAS ALSO CONSULTED AS WERE THE 0HILADELPHIA 0ANEL EVIDENCE
BASED CLINICAL PRACTICE GUIDELINES
ON SELECTED REHABILITATION INTERVENTIONS FOR SHOULDER PAIN WHICH DERIVED EVIDENCE FROM SYSTEMATIC
REVIEWS AND META
ANALYSES USING #OCHRANE METHODOLOGY BUT EXPANDED THE SEARCH STRATEGY TO INCLUDE
CASE
CONTROL COHORT AND NON
RANDOMISED STUDIES !LBRIGHT ET AL AND VAN DER (EIJDEN ET ALS
PUBLICATION 0HYSIOTHERAPY FOR PATIENTS WITH SOFT TISSUE SHOULDER DISORDERS A SYSTEMATIC REVIEW
OF RANDOMISED CLINICAL TRIALS &INALLY 4OWHEED ET AL WAS CONSULTED IN RELATION TO THE RISKS AND
BENEFITS OF NON
STEROIDAL ANTI
INFLAMMATORY MEDICATION
4HE '$' APPRAISED ORIGINAL RESEARCH ARTICLES USING A SYSTEM BASED ON 'UYATT ET AL 4HE SYSTEM IS
SHOWN IN !PPENDIX AND THE INDIVIDUAL APPRAISALS ARE TABULATED IN !PPENDIX 4O AVOID DUPLICATION
TRIALS INCLUDED IN EXISTING #OCHRANE REVIEWS WERE NOT ROUTINELY RE
APPRAISED (OWEVER SUCH RE
APPRAISAL
WAS CONDUCTED WHERE IT WAS DEEMED BY CONSENSUS THAT THIS WOULD ENHANCE THE GUIDELINES VALUE
,EVEL )6 EVIDENCE WAS OBTAINED FROM PUBLISHED CONSENSUS STATEMENTS AND GUIDELINES STANDARD
TEXTBOOKS AND COURSE MATERIAL 4HE '$' DECIDED NOT TO USE A SURVEY DUE TO THE ABSENCE OF A
MECHANISM FOR WEIGHTING ORGANISATIONS AND INDIVIDUALS CONTRIBUTIONS )T WAS FELT THAT CONTRADICTORY
VIEWS AND BIAS MIGHT OCCUR
4HE '$' THEN FORMULATED RECOMMENDATIONS GRADED ACCORDING TO THE LEVEL OF THE EVIDENCE 4ABLE
4ABLE 'RADING OF RECOMMENDATIONS AFTER .)#%
'RADE %VIDENCE
!
!T LEAST ONE RANDOMISED CONTROLLED TRIAL AS PART OF A BODY OF LITERATURE OF OVERALL GOOD QUALITY
AND CONSISTENCY ADDRESSING THE SPECIFIC RECOMMENDATION EVIDENCE LEVELS )A AND )B IN 4ABLE
"
7ELL
CONDUCTED CLINICAL STUDIES BUT NO RANDOMISED CLINICAL TRIALS ON THE TOPIC OF THE
RECOMMENDATION EVIDENCE LEVELS ))A ))B AND ))) IN 4ABLE
#
%XPERT COMMITTEE REPORTS OR OPINIONS ANDOR CLINICAL EXPERIENCE OF RESPECTED AUTHORITIES
EVIDENCE LEVEL )6 IN 4ABLE 4HIS GRADING INDICATES THAT DIRECTLY APPLICABLE STUDIES OF GOOD
QUALITY ARE ABSENT
'OOD PRACTICE POINT '00
2ECOMMENDED GOOD PRACTICE BASED ON THE CLINICAL EXPERIENCE OF THE 'UIDELINE
$EVELOPMENT 'ROUP
%VIDENCE RELATING TO DIAGNOSIS AND ASSESSMENT
4HE '$' IDENTIFIED ONE RELEVANT SYSTEMATIC REVIEW RELATING TO DIAGNOSIS AND ASSESSMENT $INNES ET AL
)T UNDERTOOK CRITICAL NARRATIVE EVALUATION OF ARTICLES BY $INNES ET AL WHICH WERE WORTHY OF
SPECIAL CONSIDERATION 2ELEVANT ARTICLES WHICH WERE OUTSIDE $INNES ET ALS SCOPE BUT IMPORTANT TO THESE
GUIDELINES WERE ALSO NARRATIVELY EVALUATED
3UCH ARTICLES WERE EVALUATED BY AT LEAST TWO OF THE '$' WHO REACHED A CONSENSUS ABOUT THE GRADING
OF THE ARTICLE THROUGH DISCUSSION (OWEVER CRITERIA FOR APPRAISING ARTICLES ON TREATMENT INTERVENTIONS
EG 'UYATT ET AL AND GRADING EVIDENCE AND RECOMMENDATIONS BASED UPON THEM EG #30
ARE NOT TRANSFERABLE TO ARTICLES ON DIAGNOSIS AND ASSESSMENT )RWIG 'LASZIOU $EEKS
#ONSEQUENTLY INDIVIDUAL DIAGNOSIS
AND ASSESSMENT
RELATED ARTICLES WERE NOT INCLUDED IN THE
TABLE OF APPRAISALS !PPENDIX NOR WERE LEVELS OF EVIDENCE OR GRADES OF RECOMMENDATIONS
SPECIFIED FOR THE DIAGNOSTICASSESSMENT LITERATURE 7E ANTICIPATE THAT FUTURE EDITIONS OF THESE GUIDELINES
WILL INCLUDE SYSTEMATIC REVIEWS OF THE ASSESSMENT LITERATURE IN LINE WITH A #OCHRANE PROTOCOL NOW UNDER
DEVELOPMENT HTTPWWWCOCHRANEORGCOCHRANESADTDOCHTM
$ISSEMINATION
4HE '$' RECOMMENDS THAT COPIES OF THE GUIDELINES BE DISTRIBUTED BY THE #30 THROUGH
s
0HYSIOTHERAPY MANAGERS
s
0HYSIOTHERAPY EDUCATORS
s
2ELEVANT PROFESSIONAL BODIES AND SPECIAL INTEREST GROUPS
s
/THER RELEVANT NATIONAL AND INTERNATIONAL BODIES
s
4HE #30S WEB SITE
7E ALSO RECOMMEND THAT THE GUIDELINES BE PRESENTED AT TRAINING WORKSHOPS #30 CONGRESS AND OTHER
APPROPRIATE NATIONAL AND INTERNATIONAL CONFERENCES
)MPLEMENTATION
%VIDENCE
BASED STANDARDISATION OF DIAGNOSIS ASSESSMENT AND MANAGEMENT OF SHOULDER IMPINGEMENT
SYNDROME WILL POTENTIALLY BENEFIT PHYSIOTHERAPY STUDENTS ANY PHYSIOTHERAPY PRACTITIONERS WHO MANAGE
THIS DISORDER IN ANY SETTING OR WHO MAY BE INVOLVED IN ITS PREVENTION THE .(3 AND OTHER HEALTH CARE
PROVIDERS AND ULTIMATELY PATIENTS 4HE GUIDELINE WILL BE USEFUL FOR FUTURE RESEARCH PURPOSES
4HE '$' HAS PRESENTED RECOMMENDATIONS BASED ON STRINGENT APPRAISAL OF THE AVAILABLE EVIDENCE
IN THE HOPE THAT THEY WILL FACILITATE THESE ENDS (OWEVER LIKE ALL INTERPRETATIONS OF EVIDENCE IT
IS NECESSARILY SUBJECTIVE )T IS NOT THE INTENTION TO IMPOSE RECOMMENDATIONS ON COLLEAGUES OR TO
COMPROMISE THEIR INDIVIDUAL AUTONOMY AS CONSUMERS OF RESEARCH .OR ARE THE GUIDELINES INTENDED TO
PRESENT AN ALTERNATIVE TO REFLECTIVE PRACTICE OR AN OBSTACLE TO INNOVATIVE PRACTICE
2EVISIONS
4HE GUIDELINES WILL BE PERIODICALLY RE
EVALUATED BY THE '$' AND REVISED SHOULD IT BE FELT THAT
SUBSTANTIVE DEVELOPMENTS HAVE OCCURRED )T IS ANTICIPATED THAT THE NEXT FULL REVISION WILL BE IN
(EALTH BENEFITS SIDE EFFECTS AND RISKS
7HERE THERE IS EVIDENCE OF SPECIFIC INTERVENTIONS OR OMISSIONS BEING ASSOCIATED WITH HEALTH BENEFITS
SIDE EFFECTS OR RISKS THIS IS STATED IN THE RELEVANT SECTIONS OF THE GUIDELINES
"ARRIERS TO IMPLEMENTATION
4O ENSURE THE SUCCESSFUL IMPLEMENTATION OF THESE GUIDELINES THE FOLLOWING QUESTIONS SHOULD BE
CONSIDERED
s
!RE ALL RELEVANT PHYSIOTHERAPY STAFF AWARE OF THE CONTENTS OF THE CLINICAL GUIDELINES AND DO THEY
HAVE ACCESS TO ADEQUATE TRAINING AS APPROPRIATE
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)S THERE AN APPROPRIATE REFERRAL SYSTEM IN PLACE ALLOWING PATIENTS ACCESS TO PHYSIOTHERAPY SERVICES
IE ARE THERE
I %STABLISHED REFERRAL PATHWAYS ACROSS CLINICAL AREAS
II !PPROPRIATE FORMS ON WHICH '0S AND CONSULTANTS MAY REFER PATIENTS WITH SHOULDER PAIN
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!RE THERE REFERRAL PATHWAYS IN PLACE FOR STEROID INJECTION TO BE CONSIDERED
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7HERE CONSERVATIVE MANAGEMENT HAS PROVED INEFFECTIVE ARE SYSTEMS IN PLACE ALLOWING REFERRAL OF
PATIENTS ON FOR ORTHOPAEDIC OPINION
s
7ILL PHYSIOTHERAPISTS BE PREPARED TO MODIFY THEIR CLINICAL PRACTICE IN LIGHT OF THE GUIDELINES
RECOMMENDATIONS
#OST IMPLICATIONS
#ONSIDERATION MAY NEED TO BE GIVEN TO THE COST IMPLICATIONS WHEN IMPLEMENTING THESE GUIDELINES
4HESE INCLUDE
s
3TAFF TRAINING
s
%QUIPMENT REQUIREMENTS EG ICE MACHINE SLING SUSPENSION RESISTANCE BANDS ULTRASOUND MACHINE
FREE WEIGHTS
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4HE DURATION OF TREATMENT SESSIONS
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4HE NUMBER OF PATIENT TREATMENT SESSIONS REQUIRED
!UDIT
! SUITABLE AUDIT TOOL TO EVALUATE THE IMPLEMENTATION OF THE GUIDELINES WILL BE DEVELOPED BY THE '$'
AND THE #30
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!LBRIGHT * !LLMAN 2 "ONFIGLIO 20 #ONILL ! $OBKIN " 'UCCIONE !! (ASSON 3 2USSO 2 3HEKELLE
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INTERVENTIONS FOR SHOULDER PAIN 0HYSICAL 4HERAPY n
"ROSSEAU , #ASIMIRO , -ILNE 3 2OBINSON 6 3HEA " 4UGWELL 0 AND 7ELLS ' $EEP
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#HARTERED 3OCIETY OF 0HYSIOTHERAPY 'UIDANCE FOR $EVELOPING #LINICAL 'UIDELINES )NFORMATION
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'UYATT '( 3ACKETT $, AND #OOK $* 5SERS GUIDE TO THE MEDICAL LITERATURE )) (OW TO USE AN
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PATIENTS *!-! n
)RWIG , AND 'LASZIOU 0 4HE #OCHRANE -ETHODS 'ROUP ON 3YSTEMATIC 2EVIEW OF 3CREENING AND
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AN OVERVIEW OF PHYSIOTHERAPEUTIC TREATMENT 0HYSIOTHERAPY n
.)#% #ITED IN #HARTERED 3OCIETY OF 0HYSIOTHERAPY 'UIDANCE FOR DEVELOPING CLINICAL
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3PEED # AND (AZLEMAN " 3HOULDER PAIN ORAL NON STEROIDAL ANTI INFLAMMATORY DRUGS
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)?COMMENTJSP
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VAN DER (EIJDEN '*-' VAN DER 7INDT $!7- AND DE 7INTER !& 0HYSIOTHERAPY FOR PATIENTS
WITH SOFT TISSUE SHOULDER DISORDERS A SYSTEMATIC REVIEW OF RANDOMISED CLINICAL TRIALS "-* n
3HOULDER IMPINGEMENT SYNDROME
$EFINITION OF SHOULDER IMPINGEMENT SYNDROME
$URING ELEVATION OF THE SHOULDER THE HUMERAL TUBEROSITIES PASS CLOSE UNDER THE CORACOACROMIAL ARCH
,ITTLE CLEARANCE IS LEFT FOR THE INTERVENING SOFT TISSUES WHICH COMPRISE FROM SUPERFICIAL TO DEEP THE
BURSA VARIOUSLY KNOWN AS @SUBACROMIAL OR @SUBDELTOID THE ROTATOR CUFF TENDONS AND THE LONG HEAD
OF BICEPS )F FOR ANY REASON THE AVAILABLE SPACE REDUCES THESE SOFT TISSUE STRUCTURES ARE LIABLE TO
BECOME PINCHED 4HIS IS CALLED @SHOULDER IMPINGEMENT SYNDROME 3)3 OR ALTERNATIVELY @SUBACROMIAL
IMPINGEMENT SYNDROME @PAINFUL ARC SYNDROME OR @CLINICAL IMPINGEMENT SYNDROME
0OSTERIOR SUPERIOR GLENOID IMPINGEMENT 03') AND SUPERIOR LABRUM ANTERIOR TO POSTERIOR 3,!0 LESIONS
WHICH MAY ALSO CAUSE IMPINGEMENT ARE CONSIDERED AS DISTINCT ENTITIES AS DEFINED BELOW 3ECTION
5NDERLYING MECHANISMS
! NUMBER OF POSSIBLE MECHANISMS UNDERLIE 3)3 SOME WELL DOCUMENTED OTHERS MORE SPECULATIVE
s
"ONY ANATOMICAL AND PATHOLOGICAL FACTORS
4HESE INCLUDE THE TYPE ))) HOOK SHAPED ACROMION PROCESS WHICH IN CADAVERIC STUDIES HAS BEEN
FOUND TO CORRESPOND WITH A HIGH LIKELIHOOD OF ROTATOR CUFF TEARS /THER BONY FACTORS IMPLICATED BY
CLINICAL EVIDENCE ARE OS ACROMIALE A MOBILE UNFUSED ANTERIOR ACROMIAL EPIPHYSIS WHICH MAY TILT
INFERIORLY AND OSTEOPHYTES PROJECTING FROM THE ACROMIOCLAVICULAR JOINT OR ACROMION
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3HOULDER INSTABILITY
2OTATOR CUFF WEAKNESS
4HE IMPORTANCE OF THE ROTATOR CUFF IN THE ACTIVE STABILISATION OF THE SHOULDER JOINT IS UNCONTROVERSIAL
)MPINGEMENT HAS BEEN PRODUCED IN CADAVERS BY SIMULATED @MUSCLE IMBALANCE 0AYNE ET AL
! RADIOGRAPHIC STUDY OF NORMAL SUBJECTS HAS SHOWN THAT THE HUMERAL HEAD MIGRATES PROXIMALLY
WHEN THE CUFF IS FATIGUED
#APSULO
LIGAMENTOUS LAXITY
#APSULO
LIGAMENTOUS LAXITY AND CONSEQUENT MINOR SUBLUXATION OF THE GLENOHUMERAL JOINT IS
WIDELY BELIEVED TO UNDERLIE IMPINGEMENT IN THE YOUNGER POPULATION ESPECIALLY IN ATHLETES SUCH AS
THROWERS AND SWIMMERS
s
)MPAIRED SCAPULOHUMERAL RHYTHM AND SCAPULAR INSTABILITY
.ORMALLY CONCURRENT MOVEMENT OF HUMERUS AND ACROMION DURING SHOULDER ELEVATION PREVENTS
IMPINGEMENT )F SCAPULAR MOTION WERE IMPAIRED IMPINGEMENT MIGHT BE EXPECTED AND IN FACT
RELATIVE TO NORMAL CONTROLS SCAPULAR MOTION DURING ELEVATION IS IMPAIRED IN PEOPLE WITH SHOULDER
IMPINGEMENT 4HIS IS LINKED TO DECREASED SERRATUS ANTERIOR ACTIVITY AND SCAPULAR INSTABILITY SUCH THAT
THE SCAPULA TENDS TO MEDIALLY ROTATE WHEN THE SHOULDER IS ELEVATED AGAINST A LOAD EMPHASISING THE
IMPORTANCE OF THE SCAPULA
CONTROLLING MUSCLES IN THIS CONNECTION ,UDEWIG AND #OOK
s
#APSULAR TIGHTNESS
! CORRELATION HAS BEEN SHOWN BETWEEN IMPINGEMENT AND POSTERIOR CAPSULAR TIGHTNESS ALTHOUGH IT
IS UNCLEAR WHICH IS CAUSE AND WHICH EFFECT 4YLER ET AL
s
0OSTURAL FACTORS
4HE POTENTIAL FOR A LINK BETWEEN POSTURE AND IMPINGEMENT MAY BE ILLUSTRATED BY ELEVATING THE ARM
IN A CORONAL PLANE WHILE SLOUCHING )T CAUSES A PAINFUL ARC PRESUMABLY BY DEPRESSING THE POINT OF
THE ACROMION AND LOWERING THE ACROMIAL ARCH
s
3OFT TISSUE CHANGES
)NFLAMMATION AND THICKENING OF THE SUBACROMIAL BURSA OR ROTATOR CUFF FOR EXAMPLE DUE TO OVERUSE
MAY RESULT IN NARROWING OF THE SUBACROMIAL SPACE AS MAY CALCIFIC THICKENING OF THE SUPRASPINATUS
TENDON 0ARTIAL ROTATOR CUFF TEARS SECONDARY TO DEGENERATIVE TENDINOPATHY ALLOW THE HUMERAL HEAD
TO MIGRATE PROXIMALLY
4HESE MECHANISMS MAY NOT BE n AND PROBABLY SELDOM ARE n MUTUALLY EXCLUSIVE !N INITIALLY SIMPLE
ISOLATED IMPINGEMENT PROBLEM MAY INITIATE A CASCADE OF EVENTS THAT INTERACT IN COMPLEX WAYS
EACH REINFORCING THE OTHER TO HINDER RESOLUTION 0AINFUL PARTIAL
THICKNESS TEARS OF THE ROTATOR CUFF
FOR EXAMPLE INHIBIT MUSCLE FUNCTION )TOI ET AL CONSEQUENT MUSCLE @IMBALANCE INCREASES
IMPINGEMENT AND INCREASED IMPINGEMENT MAY AGGRAVATE PARTIAL TEARS AND WORSEN PAIN
! VICIOUS CYCLE BECOMES ESTABLISHED AND THE EVENTUAL TENDENCY IS TOWARDS EROSION OF THE ROTATOR
CUFF .EER AND 7ELSH CLASSIFIED THIS PROCESS INTO A THREE
STAGE CONTINUUM WITH REFERENCE
TO THE APPEARANCES OF THE SUPRASPINATUS TENDON THE MOST COMMONLY INVOLVED COMPONENT OF THE
ROTATOR CUFF AND THE STRUCTURE OVERLYING IT THE SUBACROMIAL BURSA 4HEIR CLASSIFICATION IS MUCH CITED
IN THE LITERATURE
&OR AN EXTENSIVE REVIEW THE READER IS REFERRED TO "IGLIANI AND ,EVINE
.EER AND 7ELSHS CLASSIFICATION
3TAGE ) 2EVERSIBLE SUBACROMIAL OEDEMA AND HAEMORRHAGE USUALLY IN THE UNDER AGE GROUP AS
A RESULT OF OVERUSE
3TAGE )) &IBROSIS AND TENDINITIS USUALLY IN THE n AGE GROUP FOLLOWING REPEATED EPISODES OF
MECHANICAL INFLAMMATION AND IRREVERSIBLE BY CONSERVATIVE TREATMENT
3TAGE ))) "ONY CHANGES AND CUFF TEARS USUALLY IN THE OVER AGE GROUP
4HREE IMPORTANT POINTS SHOULD BE APPENDED TO THIS CLASSIFICATION
s
&IRST AS DISCUSSED BY :UCKERMAN ET AL THE ONSET OF STAGE ) IS NOT RIGIDLY RESTRICTED TO THE
UNDER GROUP BUT COULD OCCUR AT ANY AGE GIVEN THE RIGHT CONDITIONS IN PARTICULAR AN EXCESS OF
OVERHEAD ACTIVITY
s
3ECOND WHEN PROBLEMS DO OCCUR IN THE UNDER S UNDERLYING INSTABILITY SHOULD BE SPECIFICALLY
CONSIDERED )NDEED IN 0ARKER AND 3EITZS CONSECUTIVE SERIES OF PATIENTS WITH @SHOULDER
IMPINGEMENTINSTABILITY OVERLAP SYNDROME AGES RANGED UP TO YEARS MEAN YEARS
s
4HIRD RECENT WORK HAS SHOWN THAT STAGE )) IMPINGEMENT )3 RESPONSIVE TO APPROPRIATE CONSERVATIVE
TREATMENT AND IT IS BY NO MEANS CERTAIN THAT PARTIAL THICKNESS CUFF TEARS COMPONENTS OF STAGE )))
IMPINGEMENT ARE NOT "ROX ET AL
/THER TYPES OF IMPINGEMENT AT THE SHOULDER
4WO OTHER TYPES OF IMPINGEMENT ARE RECOGNISED WHOSE MECHANISMS DIFFER SUFFICIENTLY FROM THOSE
DESCRIBED ABOVE TO WARRANT SEPARATE NOMENCLATURE
0OSTERIOR SUPERIOR GLENOID IMPINGEMENT 03')
4HIS COMMONLY RESULTS FROM REPETITIVE MICROTRAUMAS SUSTAINED IN THE @THROWING POSITION EXTENSION
ABDUCTION AND EXTERNAL ROTATION )T MAY CAUSE SECONDARY JOINT
SIDE CUFF TEARS POSSIBLY INDUCING 3)3 AS
DESCRIBED ABOVE OR LABRAL DAMAGE AS DESCRIBED BELOW 4HE EXTENT TO WHICH INSTABILITY UNDERLIES THIS
CONDITION IS UNCLEAR *OBE #AVALLO AND 3PEER
3UPERIOR LABRUM ANTERIOR TO POSTERIOR 3,!0 LESIONS
4HE INCIDENCE OF 3,!0 LESIONS IS NOT KNOWN ! NUMBER OF LARGE STUDIES HAVE REPORTED THEM IN AROUND
OF ARTHROSCOPIES FOR SHOULDER PAIN EG 3NYDER ET AL (ANDELBERG ET AL "UT BY
DEFINITION THESE STUDIES RELATE TO A SELECTED SUB
GROUP OF PATIENTS AND IN THE SHOULDER PAIN POPULATION
AT LARGE 3,!0 LESIONS MAY BE LESS COMMON 3,!0 LESIONS MAY RESULT FROM TRAUMA OR DEGENERATION
BUT ARE MORE TYPICALLY ASSOCIATED WITH THROWING "ICEPS HELPS DECELERATE THE ARM AT THE END OF THE
COCKING PHASE AND LARGE TRACTION FORCES DEVELOP AT ITS ATTACHMENT TO THE SUPERIOR PART OF THE GLENOID
LABRUM !S A RESULT THE LABRUM MAY PEEL OFF THE UNDERLYING BONE HENCE THE TERM @SUPERIOR LABRUM
ANTERIOR TO POSTERIOR 3,!0 LESION 6ARYING DEGREES OF SEVERITY HAVE BEEN DESCRIBED 3NYDER ET AL
AND ALTHOUGH THE MECHANISM OF INJURY MAY BE TRACTIVE FEATURES OF IMPINGEMENT OFTEN RESULT
3TETSON ET AL
2EFERENCES SUPPORTING 3ECTION @3HOULDER IMPINGEMENT SYNDROME
"IGLIANI ,5 AND ,EVINE 7. #URRENT CONCEPTS REVIEW SUBACROMIAL IMOINGEMENT SYNDROME
*OURNAL OF "ONE AND *OINT 3URGERY
! n
"ROX *) 'JENGEDAL % 5PPHEIM ' "HMER !3 "REVIK *) ,JUNGGREN !% AND 3TAFF 0(
!RTHROSCOPIC SURGERY VERSUS SUPERVISED EXERCISES IN PATIENTS WITH ROTATOR CUFF DISEASE STAGE ))
IMPINGEMENT SYNDROME A PROSPECTIVE RANDOMISED CONTROLLED STUDY IN PATIENTS WITH A
YEAR
FOLLOW
UP *OURNAL OF 3HOULDER AND %LBOW 3URGERY n
#AVALLO 2* AND 3PEER +0 3HOULDER INSTABILITY AND IMPINGEMENT IN THROWING ATHLETES -EDICINE
3CIENCE IN 3PORTS %XERCISE 3UPPLEMENT n
(ANDELBERG & 7ILLEMS 3 3HABPOUR - (USKIN *0 AND +UTA * 3,!0 LESIONS A RETROSPECTIVE
MULTICENTER STUDY !RTHROSCOPY n
)TOI % -IAGAWA ( 3ATO 4 3ATO + AND 4ABATA 3 )SOKINETIC STRENGTH AFTER TEARS OF THE
SUPRASPINATUS TENDON *OURNAL OF "ONE AND *OINT 3URGERY
"R n
*OBE #- 0OSTERIOR SUPERIOR GLENOID IMPINGEMENT EXPANDED SPECTRUM !RTHROSCOPY THE
*OURNAL OF !RTHROSCOPIC AND 2ELATED 3URGERY n
,UDEWIG 0- AND #OOK 4- !LTERATIONS IN SHOULDER KINEMATICS AND ASSOCIATED MUSCLE ACTIVITY IN
PEOPLE WITH SYMPTOMS OF SHOULDER IMPINGEMENT 0HYSICAL 4HERAPY n
.EER # AND 7ELSH 20 4HE SHOULDER IN SPORTS /RTHOPAEDIC #LINICS OF .ORTH !MERICA
n
0ARKER 2$ AND 3EITZ 7( 3HOULDER IMPINGEMENTINSTABILITY OVERLAP SYNDROME *OURNAL OF THE
3OUTHERN /RTHOPAEDIC !SSOCIATION n
0AYNE ,: $ENG 8
( #RAIG %6 4ORZILLI 0! AND 7ARREN 2& 4HE COMBINED DYNAMIC AND STATIC
CONTRIBUTIONS TO SUBACROMIAL IMPINGEMENT A BIOMECHANICAL ANALYSIS !MERICAN *OURNAL OF 3PORTS
-EDICINE n
3NYDER 3* +ARZEL 20 $EL 0IZZO 7 &ERKEL 2$ AND &REIDMAN -* 3,!0 LESIONS OF THE SHOULDER
!RTHROSCOPY THE *OURNAL OF !RTHROSCOPIC AND 2ELATED 2ESEARCH n
3TETSON 7" 3NYDER 3* AND +ARZEL 70 ,ONG TERM FOLLOW
UP OF ISOLATED 3,!0 LESIONS OF THE
SHOULDER !RCHIVES OF THE !MERICAN !CADEMY OF /RTHOPAEDIC 3URGEONS n
4YLER 4& .ICHOLAS 3* 2OY 4 AND 'LEIM '7 1UANTIFICATION OF POSTERIOR CAPSULE TIGHTNESS AND
MOTION LOSS IN PATIENTS WITH SHOULDER IMPINGEMENT !MERICAN *OURNAL OF 3PORTS -EDICINE n
:UCKERMAN *$ -IRABELLO 3# .EWMAN $ 'ALLAGHER - AND #UOMO & 4HE PAINFUL SHOULDER
PART )) )NTRINSIC DISORDERS AND IMPINGEMENT SYNDROME !MERICAN &AMILY 0RACTITIONER n
%VIDENCE UNDERPINNING THE DIAGNOSIS AND
ASSESSMENT OF SHOULDER IMPINGEMENT SYNDROME
3UBJECTIVE ASSESSMENT
!GE
s
3)3 SPANS THE AGE RANGES OCCUPIED BY OTHER SHOULDER CONDITIONS (OWEVER IF IT IS PRESENT THE
PATIENTS AGE MAY GIVE SOME INDICATION OF ITS LIKELY STAGE SEE SECTION
s
03') TENDS TO BE SEEN IN THE UNDER S ACCORDING TO #AVALLO AND 3PEER BUT IN *OBES
SERIES OF ELEVEN PATIENTS WITH THIS CONDITION THE AGE WAS SOMEWHAT HIGHER MEAN
YEARS RANGE STANDARD DEVIATION 4HE DISCREPANCY MAY RELATE TO DIFFERENCES IN PATIENT
POPULATIONS SEE SECTION
s
3YMPTOMATIC 3,!0 LESIONS HAVE SIMILAR MECHANISMS AND A SIMILAR AGE DISTRIBUTION TO 03') WITH A
MEAN OF YEARS REPORTED BY ,IU ET AL 3,!0 LESIONS ARE SEEN IN OF CADAVERIC SHOULDERS
(AURY ET AL BUT MAY BE OF A @SILENT DEGENERATIVE TYPE ASYMPTOMATIC IN LIFE
s
!DHESIVE CAPSULITIS IS SAID TO TYPICALLY AFFECT THE n AGE GROUP .EVIASER AND .EVIASER
-ODE OF ONSET
s
3)3S MODE OF ONSET VARIES )T MAY BE INSIDIOUS OR RELATED TO A SPECIFIC INCIDENT
s
03') THOUGH COMMONLY SEEN IN SPORTSMEN AND ESPECIALLY THROWERS #AVALLO AND 3PEER IS
BY NO MEANS LIMITED TO THESE GROUPS )N *OBES SERIES OF ELEVEN PATIENTS WHO WERE ABLE TO
DESCRIBE THEIR INJURIES SIX WERE NOT SPORTSMEN ALTHOUGH THEIR INJURY MECHANISMS WERE SIMILAR TO
THROWERS /NE A FORKLIFT DRIVER HABITUALLY HORIZONTALLY EXTENDED HIS ARM RESTING IT ON HIS SEAT TO
LOOK OVER HIS SHOULDER WHILE REVERSING *OBE
s
)N ,IU ET ALS SERIES OF PATIENTS WITH 3,!0 LESIONS WERE THROWING ATHLETES AND MOST
RECALLED A TRAUMATIC EVENT
s
!CROMIOCLAVICULAR JOINT !#* OSTEOARTHRITIS IS USUALLY A LATE SEQUEL TO INJURY !MERICAN !CADEMY OF
/RTHOPAEDIC 3URGEONS
0AIN
4HE PAIN OF 3)3 FELT IN THE SHOULDER REGION OR RADIATING INTO THE ARM HAS BEEN CHARACTERISED AS SHARP
AND CATCHING OR A CHRONIC ACHE AFTER USE AND IS LIKELY TO BE AGGRAVATED BY OVERHEAD WORK 0LACING THE
HAND BEHIND THE BACK MAY ALSO HURT #LASSICALLY THERE IS A PAINFUL ARC ON ELEVATING OR LOWERING THE
ARM OR BOTH AS THE HUMERAL TUBEROSITIES PASS UNDER THE CORACO
ACROMIAL ARCH HENCE THE SYNONYM
@PAINFUL ARC SYNDROME .IGHT PAIN WHICH MAY BE SEVERE ENOUGH TO PREVENT LYING ON THE AFFECTED SIDE
IS ANOTHER COMMONLY DESCRIBED FEATURE AND IS PARTICULARLY ASSOCIATED WITH ROTATOR CUFF TEARS EG
:UCKERMAN ET AL #LINICAL EXPERIENCE SHOWS THAT NIGHT PAIN IS A COMMON FEATURE OF ADHESIVE
CAPSULITIS TOO SO CAUTION SHOULD BE EXERCISED IN ATTRIBUTING IT TO 3)3 BUT AN APPROPRIATE COMBINATION
OF AGE AND NIGHT PAIN IS SUGGESTIVE )N THIS CONNECTION ,ITAKER ET AL SHOWED ARTHROGRAPHICALLY
DETERMINED CUFF TEARS TO BE SIGNIFICANTLY P CORRELATED WITH THREE FACTORS AGE YEARS NIGHT
PAIN AND WEAK EXTERNAL ROTATION 4HESE CORRELATES WERE RESPECTIVELY ALLOCATED WEIGHTINGS OF TWO ONE
AND TWO AND A TALLY OF FOUR OR MORE WAS FOUND TO BE THE BEST PREDICTOR OF ABNORMALITY
3YMPTOMS ARISING FROM THE !#* ARE LIKELY TO BE ACCURATELY LOCALISED TO THE JOINT /STEOARTHRITIS HERE
PRODUCES ACHING AFTER ACTIVITY NIGHT PAIN DOES NOT OCCUR ALTHOUGH IN ADVANCED ARTHRITIS ROLLING ONTO
THE AFFECTED SIDE MAY PAINFULLY COMPRESS THE JOINT
.IGHT PAIN CAN ACCOMPANY 3)3 SECONDARY TO INSTABILITY OR 03') BUT IT IS LESS SEVERE THAN THAT SEEN IN
CUFF TEARS OR ADHESIVE CAPSULITIS 4HE PAIN IS ALSO MORE PREDICTABLY ACTIVITY SPECIFIC AND IN THE CASE
OF 03') MAY BE FELT POSTERIORLY REVIEWED BY #AVALLO AND 3PEER 5NFORTUNATELY THERE IS LITTLE
PREDICTABLE ABOUT SYMPTOMS ARISING FROM 3,!0 LESIONS WHICH JUDGING FROM LARGE RETROSPECTIVE
ANALYSES MAY MIMIC 3)3 3TETSON ET AL AND HAVE BEEN TERMED @VAGUE AND INCONSISTENT
(ANDELBERG ET AL
1UANTIFYING PAIN
1UANTIFYING PAIN ENABLES INTERVENTIONS EFFECTIVENESS TO BE JUDGED OVER TIME &OR THIS PURPOSE THE
VISUAL ANALOGUE SCALE 6!3 AND NUMERIC PAIN RATING SCALE .023 ARE MOST OFTEN USED "OTH HAVE BEEN
VALIDATED FOR ORTHOPAEDIC AND RHEUMATOLOGICAL USE 4HE 6!3 COMPRISES A CONTINUUM BETWEEN THE
EXTREMES OF NO PAIN AND PAIN AS BAD AS IT COULD BE REPRESENTED BY AN UNGRADUATED MM LINE
ON PAPER 0ATIENTS MARK THEIR PAIN LEVEL ON THE LINE AND THE SCORE THE DISTANCE FROM NO PAIN TO THE
PATIENTgS MARK IS THEN MEASURED BY THE CLINICIAN IN MILLIMETRES USING A RULER 3CORES ABOVE MM
CORRESPOND TO MODERATE PAIN OR WORSE AND ABOVE MM TO SEVERE PAIN OR WORSE 4EST
RETEST
RELIABILITY IS HIGH
4HE .023 REQUIRES PATIENTS TO REPRESENT THEIR PAIN INTENSITY OVER THE PREVIOUS HOURS BY CIRCLING
A NUMBER ON A
SCALE !LTERNATIVELY PATIENTS MAY VERBALLY REPORT THEIR PAIN SCORES 4EST
RETEST
RELIABILITY IS HIGH AS IS CORRELATION WITH THE 6!3 AND THE .023 IS QUICKER AND EASIER TO ADMINISTER AS
WELL AS BEING MORE MANAGEABLE FOR OLDER PEOPLE AND PEOPLE WHO DO NOT FIND READING EASY (OWEVER
BOTH 6!3 AND .023 ARE LESS SENSITIVE TO CHANGE THAN MIGHT BE IMAGINED 4O BE CONFIDENT OF CHANGE
SMALLEST DETECTABLE DIFFERENCE A VARIATION OF MM IS REQUIRED FOR THE 6!3 AND POINTS FOR THE
.023 4HIS MAY PRESENT PRACTICAL DIFFICULTIES BECAUSE THESE VALUES REPRESENT SUCH LARGE PROPORTIONS OF
THEIR RESPECTIVE SCALES &INCH ET AL
/THER SYMPTOMS
3YMPTOMS SUGGESTIVE OF UNDERLYING INSTABILITY MAY COME TO LIGHT DURING THE SUBJECTIVE ASSESSMENT
4HESE CAN INCLUDE A SENSE OF INSTABILITY APPREHENSION OF DISLOCATION ON OVERHEAD MOVEMENTS
@DEAD ARM SYNDROME WHICH CAN ACCOMPANY ANTERIOR SUBLUXATION OR PROVOCATIVE MOVEMENTS IN
MULTI
DIRECTIONAL INSTABILITY SUBJECTIVE HEAVINESS OF THE ARM OR PAINFUL CLICKING -AGAREY AND *ONES
0ARKER AND 3EITZ -AHAFFEY AND 3MITH 0AINFUL CLICKING MAY ALSO ACCOMPANY 3,!0
LESIONS ,IU ET AL #REPITUS HAS BEEN ASSOCIATED WITH PARTIAL CUFF TEARS &UKUDA ET AL
&UNCTION
&UNCTIONAL STATUS INDICES PROVIDE INVALUABLE OUTCOME MEASURES 3ELF
ASSESSMENT QUESTIONNAIRES HAVE
THE ADDED ADVANTAGES OF EMPHASISING THE PATIENTS INVOLVEMENT IN THE PROCESS AND ENABLING POSTAL
FOLLOW
UP 6ALIDATED MEASURES OF THIS TYPE INCLUDE AMONG OTHERS THE $!3( $ISABILITIES OF THE !RM
3HOULDER AND (AND QUESTIONNAIRE WHICH TAKES APPROXIMATELY FIVE MINUTES TO COMPLETE AND IS FREELY
AVAILABLE FROM
)NSTITUTE FOR 7ORK (EALTH
5NIVERSITY !VENUE 3UITE
4ORONTO /. -' %
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52, HTTPWWWIWHONCA
)NFORMATION ON MORE SHOULDER INDICES AND GENERAL GUIDANCE IS AVAILABLE FROM THE EXPANDING #30
OUTCOME MEASURES DATABASE AT
HTTPWWWCSPORGUKEFFECTIVEPRACTICEOUTCOMEMEASURESONLINEDATABASECFM
/BJECTIVE ASSESSMENT
)NSPECTION
-USCLE BULK
)N CHRONIC 3)3 ATROPHY OF THE SPINATI MAY BE MARKED -INIACI AND 3ALONEN HAVE CLEARLY ILLUSTRATED
THIS PHOTOGRAPHICALLY !TROPHY ALSO ACCOMPANIES CUFF RUPTURE AND NEUROGENIC DISORDERS
#ERVICAL AND UPPER THORACIC POSTURE
0OSTURE HAS BEEN IMPLICATED IN 3)3 AND SOME EVIDENCE SEEMS TO SUPPORT THIS 'REENFIELD ET AL
EVALUATED ASYMPTOMATIC SUBJECTS AND PATIENTS WITH UNILATERAL OR BILATERAL SHOULDER PAIN AND
REPORTED A SYSTEMATIC TENDENCY TOWARDS gFORWARD HEAD POSTUREg P BUT NO DIFFERENCE IN
MID
THORACIC POSTURE IN THE LATTER 4HE RESULTS OF THIS CAREFUL STUDY WHICH USED COMPLEX BUT
DEMONSTRABLY RELIABLE MEASUREMENT METHODS VALIDATED AGAINST X
RAY FINDINGS THEREFORE SUGGEST THAT
gFORWARD HEAD POSTUREg MAY BE RELEVANT TO 3)3 THOUGH n DUE TO THE HETEROGENEITY OF THE PATIENT GROUP
n THIS CANNOT BE STATED WITH CERTAINTY )N ADDITION #RAWFORD AND *ULL HAVE SHOWN AN INVERSE
RELATIONSHIP BETWEEN THORACIC KYPHOSIS AND THE RANGE OF ARM ELEVATION IN ASYMPTOMATIC WOMEN
AGED FROM n YEARS AND IT SEEMS REASONABLE TO SUPPOSE THAT IN THOSE WITH DECREASED RANGE THERE IS
INCREASED POTENTIAL FOR IMPINGEMENT
3TATIC SCAPULAR POSTURE
-USCLE IMBALANCE THEORISTS HAVE SPECULATED ON A TRAIN OF EVENTS WHERE PROTRACTED POSTURE STRETCHES AND
WEAKENS THE SCAPULAR ELEVATORS AND RETRACTORS DISTURBING SCAPULOHUMERAL RHYTHM AND PREDISPOSING TO
PAIN +ENDALL -C#REARY 7HETHER OR NOT THIS IS TRUE IT SEEMS PLAUSIBLE THAT RESTING SCAPULAR
POSTURES INVOLVING ABNORMAL DEPRESSION OF THE ACROMION MIGHT CONTRIBUTE TO 3)3 DISCUSSED BY "HMER
ET AL SO A THEORETICAL ARGUMENT MAY BE MADE FOR EVALUATING SCAPULAR POSTURE
)N PRACTICE THIS IS EASIER SAID THAN DONE 3CAPULAR POSTURE IS THREE
DIMENSIONAL AND COMPLEX AND TO
CHARACTERISE IT FULLY THE OBSERVER MUST TAKE ACCOUNT OF ROTATION ABOUT AN ANTERO
POSTERIOR AXIS gUPWARD
DOWNWARD ROTATIONg OR gABDUCTIONADDUCTIONg ROTATION ABOUT A VERTICAL AXIS WITH THE VERTEBRAL BORDER
BECOMING PROMINENT IN gMEDIAL ROTATIONg OR gWINGINGg AND THE REVERSE IN gLATERAL ROTATIONg AND ROTATION
ABOUT A TRANSVERSE AXIS gANTERIORPOSTERIOR TILTg )N ADDITION UPWARD AND DOWNWARD TRANSLATIONS
gELEVATIONg AND gDEPRESSIONg MAY OCCUR AS MAY TRANSLATORY MOVEMENTS TOWARDS OR AWAY FROM THE
VERTEBRAL COLUMN CONFUSINGLY REFERRED TO AS gADDUCTIONg AND gABDUCTIONg BY SOME WORKERS EG $I6ETA
ET AL g0ROTRACTIONg OR gFORWARD SHOULDER POSTUREg COMBINES TRANSLATION AWAY FROM THE VERTEBRAL
COLUMN WITH MEDIAL ROTATION WHILE THE LATERAL CLAVICLE MOVES FORWARDS RETRACTION IS THE REVERSE OF THIS
#ULHAM AND 0EAT .EIERS AND 7ORRELL ,UDEWIG AND
#OOK
#APTURING RECORDING AND INTERPRETING SO MUCH INFORMATION IS PROBLEMATIC IN THE LABORATORY LET ALONE
THE CLINIC WHERE TOOLS FOR MEASURING
$ SPACIAL RELATIONSHIPS ARE NOT AVAILABLE %VEN SO SOME
ATTEMPTS HAVE BEEN MADE TO DEVELOP SIMPLE PRACTICAL WAYS FOR CLINICIANS TO MEASURE PROTRACTION
$I6ETA ET AL DEVISED AN APPROACH USING STRING TO MEASURE FROM THE ACROMIAL ANGLE TO THE 4
SPINE gNORMALISINGg THE VALUE OBTAINED IE DIVIDING IT BY SCAPULA LENGTH TO ACCOUNT FOR INDIVIDUALSg
DIFFERENCES IN SIZE 4HESE WORKERS REPORTED FAIR RELIABILITY WITHIN
TESTERS FOR THEIR TECHNIQUE WITH
)NTRADASS #ORRELATION #OEFFICIENT )## OF FOR NORMALISED VALUES .EIERS AND 7ORRELL
3UBSEQUENT LARGE STUDIES HAVE FAILED TO REPRODUCE ACCEPTABLE RELIABILITY FOR NORMALISED VALUES BUT HAVE
REPORTED GOOD TO HIGH WITHIN
TESTER RELIABILITY FOR RAW MEASUREMENTS OF PROTRACTION SUCH THAT TRUE
VALUES WOULD BE EXPECTED TO FALL WITHIN
CMS OF MEASURED VALUES OF THE TIME .EIERS AND
7ORRELL 'IBSON ET AL 'IBSON ET AL ALSO EVALUATED BETWEEN
TESTER RELIABILITY AND
REPORTED A HIGH VALUE
!N ALTERNATIVE METHOD OF EVALUATING PROTRACTION THE gLATERAL SLIDE TESTg INVOLVES TAPE MEASURING FROM
THE INFEROMEDIAL ANGLE OF THE SCAPULA TO THE NEAREST SPINOUS PROCESS IN THREE POSITIONS ARMS AT SIDES
HANDS ON HIPS AND ARMS AT OR BELOW ABDUCTION WITH HUMERAL MEDIAL ROTATION +IBLER
!SYMMETRY GREATER THAN CM IN ANY OF THE POSITIONS IS HELD TO BE THE gTHRESHOLD OF ABNORMALITYg
+IBLER 4HE THEORETICAL APPEAL OF THE LATERAL SLIDE TEST IS ITS POTENTIAL TO CHARACTERISE SCAPULAR
POSTURE IN THREE POSITIONS BUT A NUMBER OF WELL DESIGNED STUDIES HAVE CAST DOUBT ON ITS RELIABILITY BOTH
WITHIN AND BETWEEN TESTERS 'IBSON ET AL /DOM ET AL
/VER AND ABOVE THESE QUESTIONS OF RELIABILITY IS ONE OF VALIDITY 4HE TERMS @NORMAL AND @ABNORMAL
ARE NOT VERY MEANINGFUL IN THE CONTEXT OF STATIC SCAPULAR POSTURE BECAUSE NORMATIVE WORK ON LARGE
HETEROGENEOUS SAMPLES IS LACKING AND SUCH LITERATURE AS THERE IS DOES NOT SUPPORT THE THEORETICAL LINK
BETWEEN STATIC SCAPULAR POSTURE AND 3)3 )N FACT THIS LITERATURE SUGGESTS A HIGH INCIDENCE OF BILATERAL
ASYMMETRY IN ASYMPTOMATIC SUBJECTS 3OBUSH ET AL 'REENFIELD ET AL HAVE SHOWN THAT
A MIXED DIAGNOSIS SHOULDER PAIN GROUP HAVE NO MORE TENDENCY TO THIS THAN ASYMPTOMATIC CONTROLS
4HESE FINDINGS CAST DOUBT ON THE RELEVANCE OF BILATERAL COMPARISONS IN CLINICAL EVALUATION AND MORE
FUNDAMENTALLY THE POSTULATED RELATIONSHIP BETWEEN STATIC SCAPULAR POSTURE AND 3)3
)N THIS CONNECTION RESEARCH HAS FAILED TO SUPPORT +ENDALL AND -C#REARYgS THEORISED STRETCH
WEAKENING OF THE SCAPULAR ELEVATOR AND RETRACTOR MUSCLES BY PROTRACTED POSTURE )NDEED THIS
MECHANISM IS SPECIFICALLY CHALLENGED BY $I6ETA ET AL WHO FOUND ONLY VERY WEAK CORRELATIONS
BETWEEN THE DEGREE OF POSTURAL PROTRACTION AND THE FORCE OF ELEVATION R AND RETRACTION
R &URTHERMORE 7ANG ET AL HAVE SHOWN IN ASYMPTOMATIC SUBJECTS THAT THE DEGREE
OF SCAPULAR PROTRACTION AT REST AS DETERMINED BY A VALIDATED $ ELECTROMECHANICAL DIGITISER IS
UNINFLUENCED BY STRENGTHENING THE SCAPULAR ELEVATOR AND RETRACTOR MUSCLES
%VIDENCE SUMMARY
s
!VAILABLE EVIDENCE DOES NOT SUPPORT THE CONCEPT OF A RELATIONSHIP BETWEEN STATIC SCAPULAR
POSTURE AND 3)3
&OR EXPLANATION OF ABSENCE OF LEVEL OF EVIDENCE SEE PARAGRAPH
3CAPULOHUMERAL RHYTHM
.ORMAL SCAPULOHUMERAL RHYTHM IS SMOOTHLY SYNCHRONOUS AND GROSS ABERRATIONS MAY BE OBVIOUS
CLINICALLY %VEN SO OBJECTIVE CHARACTERISATION OF THE SCAPULOHUMERAL RELATIONSHIP DURING ELEVATION HAS
PROVED ESPECIALLY DIFFICULT PRECISELY BECAUSE OF ITS DYNAMIC NATURE 4YPICALLY RESEARCHERS HAVE TRIED
TO CIRCUMVENT THIS PROBLEM BY ASSESSING THE BONESg RELATIONSHIPS IN A SERIES OF STATIC POSTURES
EG $OODY ET AL "AGG AND &ORREST BUT IT IS UNCLEAR WHETHER THESE POSTURES APPLY TO
DYNAMIC FUNCTION
)N RECENT YEARS A NUMBER OF STUDIES HAVE DYNAMICALLY EVALUATED SCAPTION SHOULDER ELEVATION IN THE
PLANE OF THE SCAPULA SEE ALSO &IG -ICHIELS AND 'REVENSTEIN ASSESSED NORMAL SUBJECTS
USING RAPID X
RAY SEQUENCES ,UDEWIG AND #OOK ASYMPTOMATIC SUBJECTS BY MEANS OF
ELECTROMAGNETIC SENSORS AND -C#LURE ET AL THREE VOLUNTEERS BY REFERENCE TO PINS INSERTED INTO
THEIR SCAPULAE !LTHOUGH PRECISE SCAPULOHUMERAL RHYTHM APPEARS TO BE UNIQUE TO INDIVIDUALS -ICHIELS
AND 'REVENSTEIN ,UDEWIG AND #OOK -C#LURE ET AL SOME GENERAL TENDENCIES
HAVE BEEN OBSERVED "ASED ON TWO OF THE THREE STUDIES -ICHIELS AND 'REVENSTEIN AND -C#LURE
ET AL IT APPEARS THAT SCAPULAR UPWARD ROTATION IS MORE OR LESS LINEAR THROUGH RANGE ESPECIALLY
BEYOND IRRESPECTIVE OF SPEED OR LOADING AND -ICHIELS AND 'REVENSTEINgS STATISTICAL ANALYSIS
DID NOT SUPPORT THE CONCEPT OF SCAPTION BEING DIVISIBLE INTO DISTINCT PHASES OF SCAPULAR ROTATION
,UDEWIG AND #OOK n WHILE ACKNOWLEDGING MARKED VARIATION IN gNORMALg SCAPULOHUMERAL RYTHM
n REPORTED A GREATER ROTATORY COMPONENT IN GENERAL BETWEEN AND BUT THEIR SUBJECTS WHO
WERE HABITUATED TO OVERHEAD WORK WERE NOT NECESSARILY REPRESENTATIVE OF A gTYPICALg POPULATION
3CAPULAR EXTERNAL ROTATION AND POSTERIOR TILTING ARE NON
LINEAR HOWEVER OCCURRING BEYOND AND
THESE MOVEMENTS ARE LARGE WITH MEAN VALUES FOR POSTERIOR TILT AND EXTERNAL ROTATION OF AND
RESPECTIVELY ACCORDING TO -C#LURE ET AL )N TOTAL SCAPULAR MOTION CONTRIBUTES ROUGHLY ONE
THIRD
OF SCAPTION RANGE -ICHIELS AND 'REVENSTEIN -C#LURE ET AL
,UDEWIG AND #OOK ALSO EVALUATED SYMPTOMATIC 3)3 PATIENTS REPORTING REDUCED SCAPULAR
ROTATION TOWARDS MORE SO WITH LOADING AND INCREASED ANTERIOR TILT AS SCAPTION APPROACHED
#ONSIDERING THE POSSIBILITY OF IMPINGEMENT UNDER THE ANTERIOR ACROMION THESE OBSERVATIONS MIGHT BE
VERY PERTINENT #ONCURRENT %-' ANALYSIS OF UPPER AND LOWER TRAPEZIUS AND SERRATUS ANTERIOR INDICATED
REDUCED ACTIVITY IN THE LATTER MUSCLE IMPLICATING IT IN THE ABNORMAL MOVEMENT PATTERN
%VIDENCE SUMMARY
s
3)3 PATIENTS DEMONSTRATE REDUCED SCAPULAR ROTATION IN MID RANGE SCAPTION MORE SO WITH LOADING
AND INCREASED ANTERIOR TILT IN THE LAST THIRD OF RANGE
&OR EXPLANATION OF ABSENCE OF LEVEL OF EVIDENCE SEE PARAGRAPH
0HYSICAL TESTS
2ANGE OF MOVEMENT
4HE PRINCIPAL DIFFERENTIATIONS TO MAKE ARE BETWEEN 3)3 3)3 SECONDARY TO INSTABILITY OTHER INTRACAPSULAR
CAUSES OF IMPINGEMENT !#* ARTHRITIS AND ADHESIVE CAPSULITIS NONE OF WHICH IS NECESSARILY MUTUALLY
EXCLUSIVE
4HERE IS CONSENSUS THAT ADHESIVE CAPSULITIS IS ASSOCIATED WITH POTENTIALLY GROSS LIMITATION OF PASSIVE
MOVEMENT MOST NOTABLY EXTERNAL ROTATION EG "UNKER LIKEWISE THAT !#* PAIN IS BEST REPLICATED
BY HORIZONTAL ADDUCTION -INIACI AND 3ALONEN 0AIN ON HORIZONTAL ADDUCTION IS NOT UNIQUE TO
THE !#* THOUGH )N #ALIS ET ALS STUDY OF PATIENTS WITH 3)3 VERIFIED BY SUBACROMIAL LOCAL
ANAESTHESIA DEMONSTRATED THIS SIGN
3OME AUTHORITIES HAVE ASSOCIATED 3)3 WITH FULL PASSIVE RANGE BY DEFINITION EG #YRIAX "UT
MOST ENVISAGE A MECHANISM WHEREBY PAIN OR WEAKNESS MAY LIMIT ACTIVE RANGE OF ELEVATION HORIZONTAL
ADDUCTION AND INTERNAL ROTATION LEADING TO ADAPTIVE SHORTENING AND MILD PASSIVE LIMITATIONS OF
MOVEMENT #ONVERSELY LIMITATIONS OF PASSIVE RANGE FROM WHATEVER CAUSE MIGHT PRECIPITATE OR
PERPETUATE IMPINGEMENT )N A CADAVERIC STUDY (ARRYMAN AND CO
WORKERS FOUND THAT TIGHTENING
THE POSTERIOR PART OF THE CAPSULE CAUSED SIGNIFICANT SUPERIOR TRANSLATION OF THE HUMERUS DURING SHOULDER
FLEXION A MECHANISM THAT HAS BEEN LIKENED TO A YO
YO ROLLING UP A STRING -ATSEN AND !RNTZ
4HERE IS ALSO EVIDENCE OF AN ASSOCIATION BETWEEN IMPINGEMENT AND POSTERIOR CAPSULAR TIGHTNESS FROM A
STUDY OF PATIENTS AND NORMAL CONTROLS BY 4YLER ET AL IN WHICH CAPSULAR TIGHTNESS WAS DETERMINED
BY PASSIVE HORIZONTAL ADDUCTION AND INTERNAL ROTATION
!LTHOUGH RANGE OF MOVEMENT AT THE SHOULDER IS COMMONLY EVALUATED BY VISUAL ESTIMATION OR UNIVERSAL
GONIOMETRY FEW STUDIES HAVE EVALUATED THESE METHODSg RELIABILITY IN SYMPTOMATIC SUBJECTS )N ONE
BY 2IDDLE ET AL RANDOMLY
PAIRED PHYSIOTHERAPISTS MEASURED PASSIVE SHOULDER RANGES IN
TWO GROUPS OF PATIENTS USING GONIOMETERS OF DIFFERENT SIZES 2ELIABILITY WITHIN
TESTERS IE THE
CONSISTENCY OF THE SAME TESTERSg MEASUREMENTS OVER TIME WAS gEXCELLENTg IRRESPECTIVE OF THE MOVEMENT
MEASURED OR THE SIZE OF GONIOMETER USED )##S n "ETWEEN
TESTERS HOWEVER RELIABILITY WAS
MOVEMENT SPECIFIC BEING gEXCELLENTg FOR COMPOSITE GLENOHUMERAL FLEXION AND ABDUCTION AND EXTERNAL
ROTATION IN ABDUCTION )##S n BUT RANGING FROM gPOORg TO gFAIRg FOR HORIZONTAL ABDUCTION AND
ADDUCTION COMPOSITE GLENOHUMERAL EXTENSION AND INTERNAL ROTATION IN ABDUCTION )##S n
4HE LATTER LOW VALUES REFLECT THIS PRAGMATIC STUDYgS DELIBERATE NON
STANDARDISATION OF PATIENT POSITIONING
AND MEASUREMENT TECHNIQUE AND CLEARLY UNDERLINE THE NEED FOR STANDARDISATION IN CLINICAL PRACTICE
-ORE RECENTLY (AYES ET AL INVESTIGATED THE RELIABILITY OF GONIOMETRY OF ACTIVE MOVEMENTS AND
VISUAL ESTIMATION OF PASSIVE MOVEMENTS AS APPLIED BY TWO PHYSIOTHERAPISTS AN ORTHOPAEDIC SURGEON
AND A TRAINEE SPORTS PHYSICIAN TO EIGHT SYMPTOMATIC SHOULDERS 'ONIOMETRY AND VISUAL ESTIMATION
WERE COMPARABLY RELIABLE FALLING IN THE gFAIR TO GOODg RANGE BOTH WITHIN
TESTERS )##S n AND
n RESPECTIVELY AND BETWEEN
TESTERS )##S n AND n "UT THE STANDARD ERRORS
ASSOCIATED WITH THESE MEASUREMENTS WERE LARGE n BETWEEN
TESTERS FOR GONIOMETRY n
FOR VISUAL ESTIMATION MEANING THAT IN THE CLINICAL SETTING ONLY GROSS CHANGES COULD BE CONFIDENTLY
ATTRIBUTED TO CHANGE IN THE PATIENTgS CONDITION AS OPPOSED TO RANDOM VARIABILITY
7ITH RESPECT TO GONIOMETRY DISCREPANCIES BETWEEN STUDIESg RESULTS MAY RELATE TO A NUMBER OF FACTORS
NOT LEAST WHETHER THE MOVEMENT BEING TESTED WAS PASSIVE OR ACTIVE )N CLINICAL PRACTICE THERE IS CASE
FOR MEASURING BOTH TYPES OF MOVEMENT WITH PASSIVE ALLOWING SPECIFIC EVALUATION OF TISSUESg RESPONSES
TO STRETCH AND ACTIVE HAVING MORE FUNCTIONAL IMPLICATIONS AND THE MESSAGE IS THAT THE TYPE OF
MOVEMENT BEING MEASURED MUST BE SPECIFIED TO AVOID AMBIGUITY 3TANDARDISATION OF PATIENT POSITIONING
AND MEASUREMENT TECHNIQUE IS EVIDENTLY AN IMPORTANT ISSUE AND THE READER IS RECOMMENDED TO CONSULT
A STANDARD TEXT OR THE EXCELLENT GONIOMETRY WEB
SITE AT HTTPACADEMICUOFSEDUFACULTYKOSMAHLE
COURSESPTGONIOMETSHABDHTM
)NCLINOMETERS HAVE ALSO BEEN USED TO EVALUATE RANGE OF MOVEMENT AT THE SHOULDER !N INCLINOMETER
RESEMBLES A CLOCK ON A FLAT RECTANGULAR BASE 4HE LONG AXIS OF THE BASE IS APPLIED ALONG THE LINE OF THE
LIMBS MOVING SEGMENT WHOSE EXCURSION IS THEN REGISTERED ON THE @CLOCK FACE IN DEGREES BY A GRAVITY
OPERATED NEEDLE ! MAJOR ADVANTAGE OF THESE DEVICES OVER UNIVERSAL GONIOMETERS IS THAT THEY CAN BE
USED ONE
HANDED LEAVING THE OPERATORS OTHER HAND FREE TO STABILISE OR TO GUIDE OR ASSIST MOVEMENT
4HEY ALSO ENABLE ACCEPTABLE RELIABILITY BETWEEN
TESTERS FOR MOST SHOULDER MOVEMENTS 'REEN ET AL
WHO INVESTIGATED THIS APPROACH ON A SMALL BUT DIVERSE PATIENT SAMPLE USING THE 0LURIMETER
6
INCLINOMETER REPORTED gEXCELLENTg RESULTS FOR ACTIVE COMPOSITE SCAPULAR AND GLENOHUMERAL FLEXION AND
ABDUCTION )##S AND RESPECTIVELY WITH THE PATIENT IN STANDING AND FOR EXTERNAL ROTATION
)## WITH THE PATIENT LYING ELBOW
AT
SIDE AND FLEXED TO A RIGHT ANGLE 4HESE VALUES COMPARE
FAVOURABLY WITH THOSE FOR GONIOMETRIC MEASUREMENT OF ACTIVE SHOULDER MOVEMENTS (OWEVER ONLY gFAIR
TO GOODg BETWEEN
TESTER RELIABILITY WAS REPORTED FOR GLENOHUMERAL FLEXION )## AND GLENOHUMERAL
ABDUCTION )## AND THE VALUE FOR MEDIAL ROTATION )## WAS DISAPPOINTING "OTH 'REEN ET
AL AND (AYES ET AL ADDITIONALLY EVALUATED AN ALTERNATIVE FUNCTIONAL MEASURE OF gINTERNAL
ROTATIONg THE gTHUMB UP BACKg TEST IN WHICH THE HIGHEST VERTEBRAL LEVEL THE PATIENT CAN REACH WITH
HIS OR HER THUMB IS RECORDED 7HILE NON
SPECIFIC TO THE SHOULDER THIS MOVEMENT IS ONE OF OBVIOUS
FUNCTIONAL IMPORTANCE ESPECIALLY FOR WOMEN 4HE LARGE DISCREPANCY IN THE BETWEEN
TESTER RELIABILITIES
REPORTED BY THESE WORKERS )##S V RESPECTIVELY PROBABLY REFLECTS HIGHER
LEVEL MANUAL SKILLS
AMONG 'REEN ET ALgS TESTERS ALL OF WHOM WERE MANIPULATIVE PHYSIOTHERAPISTS
4YLER ET AL DESCRIBED A METHOD FOR MEASURING HORIZONTAL ADDUCTION WITH THE PATIENT IN SIDE
LYING
WHICH APPEARS TO BE BOTH RELIABLE AND VALID /NE TESTER ENSURING THE PATIENT IS NEITHER TILTED FORWARDS
OR BACKWARDS FLEXES RETRACTS AND PASSIVELY STABILISES THE UPPERMOST SCAPULA 4HE SHOULDER IS PASSIVELY
ABDUCTED TO THEN GENTLY LOWERED INTO HORIZONTAL FLEXION UNTIL THE PATIENT PERCEIVES STRETCH OR THE
FOREARM DEVIATES FROM THE PERPENDICULAR INDICATING THE ONSET OF CAPSULAR TENSION ! SECOND TESTER
MEASURES THE DISTANCE BETWEEN THE PATIENTS MEDIAL EPICONDYLE AND THE COUCH USING A LARGE CARPENTERS
SQUARE 2EQUIRING TWO TESTERS THIS PROCEDURE IS SOMEWHAT IMPRACTICAL AND CLINICIANS MIGHT CONSIDER
SUBSTITUTING AN INCLINOMETER FOR THE CARPENTERS SQUARE 4HIS ADAPTATION WOULD ENABLE MEASUREMENT BY
A SINGLE TESTER BUT THE RELIABILITY OF SUCH AN APPROACH HAS YET TO BE INVESTIGATED
%VIDENCE SUMMARY
s
!CTIVE PASSIVE RANGES SHOULD BE MEASURED
s
.O METHOD OF MEASUREMENT IS ENTIRELY RELIABLE AND VALID
s
&OR PASSIVE RANGES THE UNIVERSAL GONIOMETER GIVES EXCELLENT ALL ROUND RELIABILITY WITHIN TESTERS BUT
ITS RELIABILITY BETWEEN TESTERS IS MOVEMENT SPECIFIC
s
5NIVERSAL GONIOMETRY OF ACTIVE RANGES AND VISUAL ESTIMATION OF PASSIVE RANGES ARE BOTH ASSOCIATED
WITH LARGE MEASUREMENT ERROR
s
4HE INCLINOMETERS BETWEEN TESTER RELIABILITY FOR ACTIVE RANGES IS MOVEMENT SPECIFIC "ECAUSE THE
INCLINOMETER LEAVES ONE OF THE OPERATORS HANDS FREE IT MIGHT PROVE TECHNICALLY USEFUL WHEN
MEASURING PASSIVE RANGES BUT IT HAS NOT BEEN EVALUATED IN THIS CONTEXT
s
%VALUATING MEDIAL ROTATION IS ESPECIALLY PROBLEMATIC 4HE @THUMB UP BACK TEST MAY BE USED BUT ITS
RELIABILITY DEPENDS ON SURFACE MARKING
s
!TTENTION SHOULD BE PAID TO STANDARDISING RECORDING THE TECHNIQUE USED AND TO RECORDING THE
TYPE OF RANGE BEING MEASURED IE PASSIVE OR ACTIVE
&OR EXPLANATION OF ABSENCE OF LEVEL OF EVIDENCE SEE PARAGRAPH
)NSTABILITY
)NSTABILITY MAY BE OF THREE TYPES
s
!NTERIOR INSTABILITY WHICH MAY RESULT FROM REPEATED MICROTRAUMA TO THE ANTERIOR CAPSULE OF THE
SHOULDER
s
-ULTI DIRECTIONAL INSTABILITY WHICH IS ASSOCIATED WITH GENERALISED MUSCULOSKELETAL LAXITY 0ARKER AND
3EITZ
s
0OSTERIOR INSTABILITY WHICH AS AN ISOLATED FINDING IS SELDOM ENCOUNTERED
4HERE ARE A NUMBER OF TESTS FOR THESE PROBLEMS
,OAD AND SHIFT MANOEUVRE
4HE PATIENT SITS HAND
ON
THIGH THE TESTER STABILISING THE CLAVICLE AND SCAPULA WITH ONE HAND AND
CUPPING THE HEAD OF HUMERUS WITH THE OTHER 4HE TESTER GENTLY COMPRESSES THE HUMERAL HEAD MEDIALLY
TO @LOAD IT INTO THE GLENOID AND MAINTAINS THIS LOADING WHILE MOVING IT ANTERIORLY AND THEN POSTERIORLY
-AGEE DEFINES THE ANTERIOR LOAD AND SHIFT TEST AS POSITIVE IF TRANSLATION EQUATES TO OF THE
HUMERAL HEADS DIAMETER SUCH THAT IT CAN BE FELT RIDING OVER THE EDGE OF THE GLENOID /N THE POSTERIOR
LOAD AND SHIFT TEST TRANSLATION OF UP TO OF THE HUMERAL HEADS DIAMETER IS CONSIDERED NORMAL )N
MULTI
DIRECTIONAL INSTABILITY THE TEST IS POSITIVE IN BOTH DIRECTIONS
!NTERIOR APPREHENSION TEST
4HE LOAD AND SHIFT MANOEUVRE MAY NOT ENABLE DETECTION OF VERY SUBTLE INSTABILITY AND WHERE THIS IS A
POSSIBILITY SOME AUTHORITIES PREFER THE ANTERIOR APPREHENSION TEST AND THE SUPPLEMENTARY RELOCATION
TEST SEE BELOW 4HE TESTER PASSIVELY MOVES THE SUPINE PATIENTS SHOULDER TOWARDS ABDUCTION AND
FULL LATERAL ROTATION SLOWLY AND CAREFULLY !PPREHENSION THAT THE JOINT WILL DISLOCATE GUARDING OR PAIN
ARE POSITIVE RESPONSES FOR ANTERIOR INSTABILITY ALTHOUGH PAIN IS THE MORE LIKELY RESPONSE IN PATIENTS WITH
SUBTLE NON
TRAUMATIC INSTABILITY !PPLYING AN ADDITIONAL ANTERIORLY DIRECTED FORCE HAS BEEN SHOWN
TO IMPROVE THE TESTS SENSITIVITY DISCUSSED BY #AVALLO AND 3PEER BUT A PROBLEM OF SPECIFICITY
REMAINS BECAUSE A FINDING OF PAIN IS NOT UNIQUE TO INSTABILITY
RELATED 3)3
2ELOCATION TEST FOR ANTERIOR INSTABILITY
4HIS SUPPLEMENTARY TEST IS REGARDED AS THE MOST SENSITIVE AVAILABLE FOR SUBTLE INSTABILITY #AVALLO AND
3PEER 4HE ANTERIOR APPREHENSION TEST IS PERFORMED AS ABOVE BUT WHEN THE LIMIT OF AVAILABLE
RANGE IS REACHED A POSTERIORLY
DIRECTED PRESSURE IS APPLIED TO THE HEAD OF HUMERUS )F APPREHENSION
GUARDING OR PAIN IS DIMINISHED BY THIS MANOEUVRE INSTABILITY IS LIKELY
3ULCUS TEST
7ITH THE PATIENT SITTING DOWNWARD TRACTION IS APPLIED THROUGH THE HUMERUS 4HE TEST IS POSITIVE IE
INDICATIVE OF MULTI
DIRECTIONAL INSTABILITY IF A HOLLOW SULCUS APPEARS BETWEEN THE ACROMION AND THE
HEAD OF HUMERUS -AHAFFEY AND 3MITH
%VIDENCE SUMMARY
5SEFUL TESTS FOR INSTABILITY INCLUDE
s
4HE ANTERIOR APPREHENSION TEST
s
4HE RELOCATION TEST FOR ANTERIOR INSTABILITY
s
4HE SULCUS TEST
s
4HE LOAD SHIFT MANOEUVRE
&OR EXPLANATION OF ABSENCE OF LEVEL OF EVIDENCE SEE PARAGRAPH
4ESTS OF CONTRACTILE FUNCTION
#LINICAL ASSESSMENT OF CONTRACTILE TISSUES AROUND THE SHOULDER TYPICALLY INCLUDES ACTIVE MOVEMENTS
WHICH WHILE NOT SPECIFIC TO CONTRACTILE TISSUES PROVIDE VALUABLE FUNCTIONAL INFORMATION AND ISOMETRIC
ACTIONS AGAINST MANUAL RESISTANCE DONE IN MID
RANGE IN ORDER TO MINIMISE TENSION ON NON
CONTRACTILE
TISSUES AND INCREASE SPECIFICITY ! BASELINE ISOMETRIC ASSESSMENT TRADITIONALLY COMPRISES SHOULDER
ABDUCTION AND ADDUCTION WITH THE ARM BY THE SIDE MEDIAL AND LATERAL ROTATION IN A POSITION OF NEUTRAL
HUMERAL ROTATION WITH THE ELBOW BY THE SIDE AND FLEXED TO A RIGHT ANGLE AND ELBOW FLEXION AND
EXTENSION IN THE SAME POSITION 4HE PRINCIPAL STRUCTURES PUTATIVELY TESTED BY THESE MANOEUVRES ARE
!BDUCTION
3UPRASPINATUS AND DELTOID
!DDUCTION
4ERES MINOR
,ATERAL ROTATION
)NFRASPINATUS TERES MINOR AND POSSIBLY SUPRASPINATUS
-EDIAL ROTATION
3UBSCAPULARIS
%LBOW FLEXION
"ICEPS AND BRACHIALIS
%LBOW EXTENSION
4RICEPS
0AIN IS HELD TO DENOTE A MINOR LESION COMBINED PAIN AND WEAKNESS A MORE SUBSTANTIAL LESION EG A
PARTIAL TEAR AND PAINLESS WEAKNESS EITHER A NEUROGENIC PROBLEM SUCH AS SUPRASCAPULAR NEURITIS OR A
COMPLETE TEAR OF A CUFF TENDON #YRIAX 5P TO A POINT THESE ASSERTIONS APPEAR TO BE VALID )TOI
ET AL TESTING THESE ACTIONS WITH AN ISOKINETIC DYNAMOMETER DEMONSTRATED PAIN AND WEAKNESS
MOST MARKED INTO ABDUCTION n REDUCTION IN FORCE AND LATERAL ROTATION n REDUCTION
IN FORCE IN PATIENTS WITH VARYING DEGREES OF ISOLATED SUPRASPINATUS TEAR 5SE OF LOCAL ANAESTHESIA TO
ABOLISH THE PAIN ROUTINELY ENHANCED FORCE PRODUCTION WHICH IN THE CASE OF PARTIAL THICKNESS TEARS
RETURNED TO NEAR NORMAL LEVELS &ULL THICKNESS TEARS DID NOT DEMONSTRATE SO COMPLETE A RECOVERY
PRESUMABLY REFLECTING A STRUCTURAL INABILITY TO OPTIMALLY TRANSMIT FORCE "OTH OUTCOMES WOULD APPEAR TO
FIT WITH CONVENTIONAL WISDOM
9ET SOME OF )TOI ET ALgS RESULTS WERE LESS PREDICTABLE SUGGESTING COMPLEX INTERACTIONS BETWEEN
CONTRACTILE STRUCTURES .OTABLY ADDUCTION AND MEDIAL ROTATION FORCE WERE ALSO IMPAIRED BY ISOLATED
SUPRASPINATUS TEARS AND BOTH IMPROVED AFTER LOCAL ANAESTHESIA THE LATTER SIGNIFICANTLY SO POSSIBLY
REFLECTING THE CUFFgS INTEGRATED STABILISING ROLE (ENK ET AL &URTHERMORE )TOI ET AL FAILED
TO FIND THE EXPECTED INVERSE RELATIONSHIP BETWEEN THE AREA AS OPPOSED TO THE DEPTH OF THE TEAR AND
FORCE 4HEY EXPLAIN THIS IN TERMS OF VARIABLE MINGLING AND OVERLAPPING OF INDIVIDUAL TENDONS FIBRES
WITHIN THE CUFF !TROPHY WHICH MAY OCCUR RAPIDLY AFTER CUFF TEAR IS A FURTHER CONFOUNDING VARIABLE AND
CONSIDERING THESE FACTORS AS WELL AS THE FACT THAT INFRASPINATUS AND SUBSCAPULARIS ARE NOW BELIEVED TO
CONTRIBUTE AS MUCH TO ABDUCTION AS SUPRASPINATUS /TIS ET AL 3HARKEY ET AL IT WOULD SEEM
THAT ISOLATING INDIVIDUAL CUFF MUSCLES BY MANUAL TESTING MIGHT BE HARDER THAN WAS PREVIOUSLY SUPPOSED
)N VIEW OF SUCH DIFFICULTIES +ELLY ET AL SOUGHT TO IDENTIFY THE ISOMETRIC ACTIONS THAT WOULD MOST
EFFECTIVELY AND SELECTIVELY ACTIVATE THE INDIVIDUAL ROTATOR CUFF MUSCLES !N %-' ANALYSIS OF SUPRASPINATUS
INFRASPINATUS SUBSCAPULARIS AND FIVE SHOULDER MUSCLE SYNERGISTS WAS THEREFORE UNDERTAKEN DURING
VARIOUS ISOMETRIC ACTIONS IN NORMAL SUBJECTS &OR SUPRASPINATUS RESISTED SCAPTION AT WITH
THE THUMB POINTING UPWARDS THE gFULL CANg POSITION PRODUCED THE GREATEST ACTIVATION WITH THE LEAST
CONCURRENT ACTIVATION OF INFRASPINATUS AND DEMONSTRATED EXCELLENT TEST RETEST RELIABILITY RELIABILITY
COEFFICIENT 4HE ALTERNATIVE gEMPTY CANg TEST IN WHICH SCAPTION IS RESISTED WITH THE THUMB POINTING
DOWNWARDS WHEN USED ON THE ABOVE GROUP WAS MARGINALLY LESS SPECIFIC AND RELIABLE
4HE OPTIMAL
ACTION FOR TESTING INFRASPINATUS WAS AS FOR THE TRADITIONAL METHOD BUT WITH OF MEDIAL ROTATION AT
THE SHOULDER THIS MINIMISED CO ACTIVATION OF SUPRASPINATUS AND POSTERIOR DELTOID AND HAD EXCELLENT
TEST RETEST RELIABILITY COEFFICIENT /F THE ACTIONS FOUND TO BE RELIABLE FOR TESTING SUBSCAPULARIS
THE g'ERBER PUSH WITH FORCEg TEST RELIABILITY COEFFICIENT RESULTED IN THE GREATEST ACTIVATION OF THIS
MUSCLE WITH LEAST CO ACTIVATION OF THE PECTORAL AND LATISSIMUS DORSI MUSCLES )N THIS TEST THE PATIENT
WHO IS SITTING RESTS THE DORSUM OF THE HAND AGAINST THE SMALL OF HIS OR HER BACK AT WAIST BELT LEVEL THEN
ATTEMPTS TO LIFT IT OFF POSTERIORLY AGAINST THE EXAMINERgS RESISTANCE
)N CLINICAL USE THE @EMPTY CAN TEST IS MORE LIABLE TO HURT BUT THE PAIN IS AS LIKELY TO BE DUE TO POSITIONAL IMPINGEMENT
AS IT IS TO TENSION IN SUPRASPINATUS SO ITS IMPLICATIONS ARE AMBIGUOUS THE @FULL CAN TEST IS THEREFORE PREFERRED
)TOI ET AL
%VIDENCE SUMMARY
4HE MOST EFFECTIVE AND SELECTIVE MUSCLE TESTS FOR THE ROTATOR CUFF ARE
s
4HE @FULL CAN TEST FOR SUPRASPINATUS
s
4HE @'ERBER PUSH WITH FORCE TEST FOR SUBSCAPULARIS
s
2ESISTED LATERAL ROTATION FROM OF MEDIAL ROTATION FOR INFRASPINATUS
&OR EXPLANATION OF ABSENCE OF LEVEL OF EVIDENCE SEE PARAGRAPH
4HESE MODIFIED ISOMETRIC TESTS MAY BE SUBSTITUTED FOR THOSE IN STANDARD USE BUT SINCE THEY INVOLVE
TESTING IN NON
NEUTRAL JOINT POSITIONS IT IS IMPORTANT TO BE CLEAR AS TO WHETHER THE NON
CONTRACTILE OR
CONTRACTILE TISSUES ARE THE SOURCE OF ANY PAIN EVOKED
! QUESTION ARISES AS TO HOW CONTRACTILE FORCE MIGHT BE QUANTIFIED AND RECORDED 4HE n SCALE IS
INAPPROPRIATE SINCE IT RELATES TO ISOTONIC NOT ISOMETRIC MUSCLE ACTIONS AND ALSO BECAUSE IN THIS PATIENT
GROUP NEARLY ALL SCORES WOULD FALL WITHIN GRADES n /N THE BASIS OF ANTHROPOMETRIC MEASURES $VIR
HAS CALCULATED THAT SHOULDER MUSCLES ASSESSED AS GRADE MAY GENERATE AS LITTLE AS OF THEIR
MAXIMAL FORCE )SOKINETIC DYNAMOMETERS ARE COSTLY NOT ACCESSIBLE TO ALL AND IN ANY EVENT IMPRACTICAL
FOR EVERYDAY USE (OWEVER THE USE OF A DIGITAL @ISOMETRIC DYNAMOMETER SHOULD BE CONSIDERED
(AND
HELD ISOMETRIC DYNAMOMETERS ARE AVAILABLE AS WELL AS @FIXED VERSIONS THAT CAN BE TEMPORARILY
ATTACHED TO BARS OR BENCHES "RINKMANN HAS REPORTED THE TWO TYPES TO BE INTERCHANGEABLE
WHEN MEASURING THE RELATIVELY LOW FORCES GENERATED BY PATIENTS WITH NEUROMUSCULAR DISEASE 0EARSON
CORRELATION COEFFICIENTS n )N MUSCULOSKELETAL PRACTICE THOUGH HIGHER FORCES MIGHT BE
ENCOUNTERED AND IF THE THERAPISTS STRENGTH AND TECHNIQUE ARE INADEQUATE TO RESIST THE PATIENTS EFFORT
THEN IT IS THE THERAPISTS NOT THE PATIENTS STRENGTH THAT WILL BE MEASURED BY A HAND
HELD DEVICE &OR
THIS REASON @FIXED TYPE DYNAMOMETERS WOULD SEEM THEORETICALLY PREFERABLE BUT RESEARCH EVIDENCE HAS
NOT SUBSTANTIATED THIS 0HILLIPS ET AL @BREAK TESTED UPPER
AND LOWER LIMB MUSCLE GROUPS IN A
CONVENIENCE SAMPLE OF NORMAL SUBJECTS AGED n YEARS USING A HAND
HELD DYNAMOMETER AND
DEMONSTRATED RELIABILITY COEFFICIENTS OF FOR BOTH INTRA
AND INTERSESSION RELIABILITY FOR ALL GROUPS
EXCEPT THE ANKLE DORSIFLEXORS (AND
HELD DYNAMOMETERS GREAT ADVANTAGE IS THEIR EASE OF APPLICATION
3PECIFIC TESTS FOR COMPLETE CUFF TEARS
$ROP ARM TEST
4HE PATIENT ACTIVELY ABDUCTS THE SHOULDER TO BEFORE BEING ASKED TO LOWER IT SLOWLY 4HE TEST IS
POSITIVE IF THE ARM IMMEDIATELY DROPS WITH PAIN 4HIS IS A HIGHLY SPECIFIC TEST FOR A CUFF TEAR AND IF IT IS
POSITIVE SUCH A LESION IS NEAR CERTAIN 4HE CONVERSE DOES NOT HOLD TRUE HOWEVER SO A NEGATIVE DROP
ARM TEST DOES NOT PROVE THE ABSENCE OF A TEAR $INNES ET AL
,IFT OFF TEST
4HIS IS @'ERBERS PUSH WITH FORCE TEST PERFORMED WITHOUT RESISTANCE )F THE PATIENT IS UNABLE TO
ACTIVELY LIFT THE DORSUM OF THE HAND FROM HIS OR HER BACK IN SPITE OF HAVING ADEQUATE PASSIVE RANGE A
SUBSCAPULARIS TEAR IS ALMOST CERTAINLY PRESENT $INNES ET AL
3PECIFIC IMPINGEMENT TESTS
#OMMONLY USED IMPINGEMENT TESTS INCLUDE .EERgS TEST THE (AWKINS
+ENNEDY TEST AND THE PAINFUL ARC
.EERgS TEST
!S ORIGINALLY DESCRIBED THIS TEST IS IN TWO PARTS &IRST THE CLINICIAN FORCIBLY FLEXES THE SITTING PATIENTgS
ARM PREVENTING SCAPULAR MOVEMENT BY PRESSING DOWN ON THE CLAVICLE AND ACROMION WITH THE OTHER
HAND 4HIS IS PAINFUL IN IMPINGEMENT BUT IN OTHER CONDITIONS TOO )N IMPINGEMENT THOUGH INJECTION
OF LOCAL ANAESTHETIC INTO THE SUBACROMIAL SPACE ABOLISHES THE PAIN ON TESTING 4HE INJECTION AND RETEST
COMPRISE THE SECOND PART OF .EERgS TEST .EER BUT IN PRACTICE ARE OFTEN OMITTED ! SHOULDER
MEDIAL ROTATION COMPONENT WAS NOT SPECIFIED IN THE ORIGINAL DESCRIPTION OF THE TEST BUT HAS COME TO
BE ASSUMED BY OTHER WORKERS INCLUDING 6ALADIE ET AL WHO HAVE DEMONSTRATED THE ANATOMICAL
VALIDITY OF .EERgS TEST n THUS MODIFIED n AND THE (AWKINS
+ENNEDY TEST ON CADAVERS )N THE .EERgS
TEST POSITION CONTACT BETWEEN THE GREATER TUBEROSITY AND LATERAL ACROMION WAS DEMONSTRATED IN
SPECIMENS SOFT TISSUE CONTACT ON THE MEDIAL ASPECT OF THE ACROMION IN )N THE LONG HEAD
OF BICEPS TENDON LAY BENEATH THE ACROMION AND IN THE CORACOACROMIAL LIGAMENT IT COULD NOT BE
SEEN IN THE REMAINING SPECIMEN )N THE TWO SPECIMENS IN WHICH THE CORACOACROMIAL LIGAMENT COULD BE
VISUALISED THE LIGAMENT WAS IN CONTACT WITH THE LESSER TUBEROSITY IN ONE AND BOTH TUBEROSITIES AND THE
BICEPS TENDON IN THE OTHER )N SPECIMENS THERE WAS EVIDENCE OF CONTACT BETWEEN THE JOINT SIDE OF
THE CUFF TENDONS AND THE GLENOID RIM EITHER SUPERIORLY OR ANTERIORLY 6ALADIE ET AL
(AWKINS
+ENNEDY TEST
4HE CLINICIAN POSITIONS THE PATIENTgS ARM AT OF FORWARD FLEXION THEN FORCIBLY INTERNALLY ROTATES THE
SHOULDER 4HIS TEST AIMS TO REPRODUCE THE PATIENTgS PAIN BY gIMPALINGg THE SUPRASPINATUS TENDON AGAINST
THE UNDERSIDE OF THE CORACOACROMIAL LIGAMENT (AWKINS AND +ENNEDY )N 6ALADIE ET ALgS
CADAVERIC STUDY SHOULDERS PLACED IN THE (AWKINS
+ENNEDY POSITION DEMONSTRATED CONTACT BETWEEN THE
GREATER TUBEROSITY AND LATERAL ACROMION IN SPECIMENS BETWEEN THE BURSAL SIDE OF THE CUFF TENDONS
AND THE MEDIAL ACROMION IN AND BETWEEN THE CUFF OR BICEPS TENDON AND THE CORACO
ACROMIAL
LIGAMENT IN 4HE BICEPS TENDON LAY UNDER THE CORACO
ACROMIAL LIGAMENT IN SPECIMENS AND IN ALL
THERE WAS CONTACT BETWEEN THE JOINT SIDE OF THE CUFF TENDONSg AND THE GLENOID RIM ANTEROSUPERIORLY
4HE ANATOMICAL RATIONALES FOR THE .EER AND (AWKINS
+ENNEDY TESTS ARE THEREFORE SOUND )N ADDITION
THESE TESTS DIAGNOSTIC ACCURACIES HAVE BEEN EVALUATED IN STUDIES USING SUBACROMIAL LOCAL ANAESTHESIA
AND ARTHROSCOPIC APPEARANCES RESPECTIVELY AS @GOLD STANDARDS #ALIS ET AL -AC$ONALD ET
AL #ALIS ET AL AND -AC$ONALD ET AL REPORTED SENSITIVITIES OF AND
RESPECTIVELY FOR .EERS TEST AND BOTH REPORTED SENSITIVITY FOR THE (AWKINS
+ENNEDY TEST "UT
SPECIFICITIES WERE MUCH LOWER AND FOR .EERgS AND AND FOR THE (AWKINS
+ENNEDY 4HE CLINICAL IMPLICATION IS THAT A POSITIVE TEST RESPONSE CANNOT BE CONFIDENTLY ASCRIBED TO
IMPINGEMENT BUT THAT IF THERE IS A NEGATIVE RESPONSE IMPINGEMENT IS VERY UNLIKELY
0AINFUL ARC
0AINFUL ARC IS USUALLY ELICITED DURING ACTIVE ELEVATION OR LOWERING THROUGH THE CORONAL PLANE AND IS
CHARACTERISED BY ONSET AND OFFSET OF PAIN SOMEWHERE IN THE n RANGE +ESSEL AND 7ATSON
#ALIS ET AL EVALUATED IMPINGEMENT TESTS AGAINST A CRITERION OF SUBACROMIAL LOCAL
ANAESTHESIA IN RELATIVELY UNSELECTED PATIENTS WITH SHOULDER PAIN AND REPORTED A SENSITIVITY OF
MUCH LOWER THAN THOSE OF .EERgS AND THE (AWKINS
+ENNEDYS TESTS "UT THE PAINFUL ARC WAS
MUCH MORE SPECIFIC 4HIS WOULD SUGGEST THAT IMPINGEMENT CANNOT BE RULED OUT ON THE
STRENGTH OF A NEGATIVE RESPONSE BUT CAN PROBABLY BE RULED IN IF AN ARC IS PRESENT
! LARGE RETROSPECTIVE STUDY BY ,ITAKER ET AL HAS YIELDED CONFLICTING RESULTS IE A SENSITIVITY VALUE
OF APPROXIMATELY AND SPECIFICITY OF APPROXIMATELY FOR PAINFUL ARC AND A HIGHLY MODIFIED
.EERS TEST "UT THESE RESULTS MAY BE MISLEADING /NLY CUFF TEARS WERE COUNTED AS TRUE POSITIVES SO
PAINFUL ARCS RIGHTLY IDENTIFYING OTHER CUFF PATHOLOGIES OR BURSITIS WOULD HAVE REGISTERED AS FALSE POSITIVE
RESULTS )N ADDITION DOUBLE CONTRAST ARTHROGRAPHY THE DIAGNOSTIC GOLD STANDARD USED IS OF DOUBTFUL
VALIDITY
/N THE OTHER HAND AS DEMONSTRATED BY 9AMAKADO AND OTHERS SINGLE DIAGNOSTIC BLOCKS
ARE THEMSELVES NOT NECESSARILY RELIABLE BUT THE LEVEL OF AGREEMENT BETWEEN #ALIS ET AL AND
-AC$ONALD ET AL IN RESPECT OF OTHER IMPINGMENT TESTS PROVIDES REASSURING CONVERGENT VALIDITY
%VIDENCE SUMMARY
s
.EGATIVE .EER (AWKINS +ENNEDY TESTS LARGELY RULE IMPINGEMENT OUT BUT POSITIVE RESULTS DO NOT
RULE IT IN WITH ANY CERTAINTY
s
! @PAINFUL ARC PROBABLY RULES IMPINGEMENT IN BUT THE ABSENCE OF AN ARC DOES NOT RULE IT OUT WITH
ANY CERTAINTY
&OR EXPLANATION OF ABSENCE OF LEVEL OF EVIDENCE SEE PARAGRAPH
$IFFERENTIATION FROM OTHER INTRACAPSULAR CAUSES OF IMPINGEMENT
)NTERNAL ROTATION RESISTANCE STRENGTH TEST
0AIN ON IMPINGEMENT TESTS MAY INDICATE INTRA
ARTICULAR LESIONS 3,!0 LESIONS MINOR INSTABILITY AND 03')
AND A NUMBER OF TESTS HAVE BEEN DEVELOPED TO DIFFERENTIATE BETWEEN THESE AND THE MORE COMMON
CAUSES OF IMPINGEMENT 4HE INTERNAL ROTATION RESISTANCE STRENGTH TEST )2234 HAS BEEN DESCRIBED
BY :ASLAV 4HE PATIENT STANDS WITH THE ARM HELD IN ABDUCTION AND n EXTERNAL
ROTATION )N THIS POSITION A MANUAL ISOMETRIC MUSCLE TEST OF EXTERNAL ROTATION THEN INTERNAL ROTATION
IS PERFORMED AND THE STRENGTH OF THE TWO MOVEMENTS COMPARED .O CONTRALATERAL COMPARISON IS
MADE BECAUSE THE TEST IS OF RELATIVE WEAKNESS IN A gPATHOLOGICg SHOULDER )F IN A PATIENT WITH SIGNS OF
IMPINGEMENT EXTERNAL ROTATION IS STRONG BUT INTERNAL WEAK THE TEST IS REGARDED AS POSITIVE FOR INTERNAL
IMPINGEMENT :ASLAV SPECULATES THAT ISOMETRIC INTERNAL ROTATION PUSHES THE HEAD OF HUMERUS
ANTERIORLY TENSIONING THE CAPSULOLABRAL BORDER AND BICEPS
LABRAL COMPLEX MAGNIFYING THE PAIN OF
SUBTLE SUBLUXATION AND BICEPS AND 3,!0 LESIONS AND CAUSING APPARENT RATHER THAN ACTUAL WEAKNESS
4HE MECHANISM BY WHICH THIS TEST WOULD IDENTIFY POSTERIOR
SUPERIOR IMPINGEMENT IS LESS CLEAR
CUT
#OMPARISON WITH ARTHROSCOPIC FINDINGS INDICATES THAT THE )2234 IS HIGHLY SENSITIVE AND SPECIFIC
IN DIFFERENTIATING BETWEEN SUBACROMIAL IMPINGEMENT AND INTRA
ARTICULAR IMPINGEMENT :ASLAV
ALTHOUGH THESE RESULTS HAVE NOT BEEN INDEPENDENTLY VERIFIED
0ALPATION
/PTIMAL POSITIONS FOR ACCESSING THE ROTATOR CUFF AND BICEPS TENDONS HAVE BEEN DESCRIBED BY -ATTINGLEY
AND -ACKAREY ON THE BASIS OF CADAVERIC WORK
3UPRASPINATUS
4HE DISTAL TENDON IS MAXIMALLY EXPOSED WITH THE LEAST AMOUNT OF OVERLYING TISSUE IN THE FOREARM
BEHIND
THE
BACK POSITION WITH MAXIMAL ADDUCTION AND HYPEREXTENSION n )T THEN LIES IMMEDIATELY
ANTERIOR TO THE ACROMIO
CLAVICULAR JOINT BUT CANNOT BE DISTINGUISHED BY TOUCH ATTEMPTING TO LOCALISE
IT BY RESISTING SHOULDER ABDUCTION AND FEELING FOR INCREASED TENSION IS UNHELPFUL SINCE THIS ACTION ALSO
TENSES THE OVERLYING DELTOID
)NFRASPINATUS AND TERES MINOR
4HE OPTIMAL POSITION IS OF SHOULDER FLEXION OF ADDUCTION AND OF LATERAL ROTATION AND
WHETHER THIS IS ACHIEVED IN SITTING OR LYING APPEARS TO BE IRRELEVANT 4HE DISTAL TENDON LIES IMMEDIATELY
INFEROLATERAL TO THE ANGLE OF THE ACROMION 4HE DISTAL TERES MINOR TENDON IS IMMEDIATELY INFERIOR TO THAT
OF INFRASPINATUS
3UBSCAPULARIS AND THE LONG HEAD OF BICEPS
4HE SUBSCAPULARIS TENDON IS BROUGHT INTO THE DELTOPECTORAL TRIANGLE AND THEREFORE SUPERFICIAL BY
POSITIONING THE SHOULDER IN NEUTRAL ABDUCTION
ADDUCTION AND NEUTRAL ROTATION 3LIGHT MEDIAL ROTATION
BRINGS THE LONG HEAD OF BICEPSg TENDON IN ITS GROOVE INTO THE TRIANGLE
4HESE POSITIONS BROADLY AGREE WITH THOSE PREVIOUSLY DESCRIBED BY #YRIAX AND #YRIAX
2ECOMMENDATIONS FOR DIAGNOSISASSESSMENT
(ISTORY
4HIS SHOULD SPECIFICALLY ESTABLISH
s
4HE PATIENTS AGE
3)3
4HIS MAY OCCUR AT ANY AGE BUT IN PATIENTS UNDER YEARS OLD IS LIKELY TO BE SECONDARY TO INSTABILITY
03') 3,!0
&OR BOTH THE MEAN AGE IS APPROXIMATELY YEARS RANGE APPROXIMATELY n
#APSULITIS
4HE USUAL AGE RANGE IS
YEARS
s
(OW THE PROBLEM STARTED
3)3
4HE ONSET MAY BE SUDDEN OR INSIDIOUS
03')
4HIS IS USUALLY RELATED TO THROWING OR AN ANALOGOUS INJURYACTIVITY
3,!0
3,!0 LESIONS ARE USUALLY ATTRIBUTABLE TO SPECIFIC THROWING
RELATED INCIDENTS
!#* ARTHRITIS
3YMPTOMS USUALLY DEVELOP MANY YEARS AFTER AN INJURY
s
4HE NATURE OF THE SYMPTOMS
6ARIOUS SYMPTOMS AND THEIR LIKELY IMPLICATIONS ARE PRESENTED IN TABLE
s
4HE INTENSITY OF THE PAIN
5SE A 6!3 OR EQUIVALENT
&UNCTIONAL STATUS
4HE PATIENTS FUNCTIONAL STATUS SHOULD BE DETERMINED USING AN APPROPRIATE VALIDATED TOOL EG
$ISABILITIES OF THE !RM 3HOULDER AND (AND AVAILABLE FROM )NSTITUTE FOR 7ORK (EALTH 5NIVERSITY
!VENUE 3UITE 4ORONTO /. -' % &!8
$!3( IWHONCA OR
HTTPWWWIWHONCA
4ABLE $IFFERENTIAL DIAGNOSIS A SUMMARY OF SHOULDER SYMPTOMS
#ONDITION
3YMPTOM
3)3
0AIN
3)3
03')
SECONDARY TO
INSTABILITY
3,!0
#APSULITIS
!#*
ARTHRITIS
3HOULDER
DELTOID
-AY RADIATE
INTO ARM
,OCAL TO !#*
0OSTERIOR
)NSIDE JOINT
VAGUE
3HARP
CATCHING
!CHING
!T NIGHT
0OSSIBLE
SUGGESTS
CUFF TEAR
0OSSIBLE
BUT MINOR
0OSSIBLE
BUT MINOR
0OSSIBLE
,YING ON
0OSSIBLE
AFFECTED SIDE SUGGESTS
CUFF TEAR
0OSSIBLE
0OSSIBLE
!CTIVITY
SPECIFIC
%SPECIALLY
OVERHEAD
WORK
!S FOR 3)3
4HROWING
OR SIMILAR
.OT
CONSISTENT
0OSSIBLE
!CHE AFTER
GENERAL
ACTIVITY
$EAD ARM
0OSSIBLE
(EAVY
FEELING
0OSSIBLE
0AINFUL
CLICKING
0OSSIBLE
0OSSIBLE
0OSSIBLE
#REPITUS
0OSSIBLE
SUGGESTS
PARTIAL
CUFF TEAR
0OSSIBLE
0HYSICAL ASSESSMENT
)NSPECTION
7ITH THE PATIENT IN STANDING AND SITTING BOTH POSITIONS MAY BE PERTINENT LOOK FOR
s
@&ORWARD HEAD POSTURE
s
%XCESSIVE THORACIC KYPHOSIS
!LSO LOOK FOR
s
-USCLE ATROPHY ESPECIALLY OF THE SPINATI
s
"RUISING WHICH MAY ACCOMPANY CUFF TEARS
4HE VALUE OF ASSESSING STATIC SCAPULAR POSTURE IS DOUBTFUL BUT LOOK FOR
s
$EFINITE SCAPULAR WINGING WHICH MAY RAISE SUSPICIONS OF SERRATUS ANTERIOR DYSFUNCTION AS IN LONG
THORACIC NEURITIS 4HIS MAY BE FURTHER EVALUATED BY INSPECTING FOR WINGING WHILE THE PATIENT
PROTRACTS AGAINST RESISTANCE EG PUSHING ONE
ARMED AGAINST A WALL
/N ACTIVE SCAPTION LOOK FOR
s
2EDUCED SCAPULAR ROTATION IN THE MIDDLE THIRD OF RANGE !BNORMALITY MAY BE ACCENTUATED WHEN
THE SCAPTION MOVEMENT IS PERFORMED AGAINST RESISTANCE IN THE ORDER OF +G ,UDEWIG AND #OOK
s
/THER DISTURBANCE OF SCAPULOHUMERAL RHYTHM WHICH MAY BE ASSOCIATED WITH A PAINFUL ARC
#OMPARISON WITH THE UNAFFECTED SIDE IS NOT FOOLPROOF BUT THE BEST AVAILABLE BENCHMARK OF NORMALITY
!NY OF THESE FACTORS MAY BE ASSOCIATED WITH 3)3
0HYSICAL TESTS
2ANGE OF MOVEMENT
0RELIMINARILY CLEAR THE CERVICAL SPINE AS A SOURCE OF SYMPTOMS
%VALUATE THE MOBILITY OF THE THORACOLUMBAR SPINE DURING ELEVATION THE SHOULDER MUST COMPENSATE FOR
STIFFNESS HERE AND AS FAR AS POSSIBLE LOCALISE ANY STIFFNESS FOUND
4HEN AT THE SHOULDER EVALUATE
s
!CTIVE RANGE AND
s
0ASSIVE RANGE
.OTE THE PRESENCE OR ABSENCE OF PAIN AS WELL AS THE AVAILABLE RANGE OF MOVEMENT FOR EACH 4HE '$'
RECOMMENDS THAT AN INCLINOMETER BE CONSIDERED FOR MEASURING COMPOSITE ELEVATION AND SHOULDER
LATERAL ROTATION THE LATTER WITH THE PATIENT SUPINE AND THE ELBOW ADDUCTED
!T THE PRESENT TIME THERE IS NO EVIDENCE THAT PURE MEDIAL ROTATION CAN BE MEASURED RELIABLY 4HIS IS
UNFORTUNATE BECAUSE LIMITATION REFLECTS POSTERIOR CAPSULAR TIGHTNESS WHICH SEEMS TO BE ASSOCIATED WITH
3)3 ! GROSS IMPRESSION OF MEDIAL ROTATION RANGE MAY BE FORMED BY VISUAL COMPARISON WITH THAT OF THE
UNAFFECTED SIDE !LTERNATIVELY THE @THUMB UP BACK TEST MAY BE USED IN WHICH THE CLINICIAN RECORDS THE
HIGHEST VERTEBRAL LEVEL REACHED 4HIS TESTS MORE THAN MEDIAL ROTATION OF COURSE AND ALSO DEPENDS
ON THE THERAPISTS ABILITY TO IDENTIFY THE RELEVANT SPINAL LEVEL 0ASSIVE HORIZONTAL ADDUCTION EVALUATES
THE EXTENSIBILITY OF THE POSTERIOR CAPSULE TOO AND SHOULD BE INCLUDED 4HE TECHNIQUE IS DESCRIBED IN
SECTION
0OSSIBLE FINDINGS ON RANGE OF MOVEMENT TESTING AND THEIR LIKELY IMPLICATIONS ARE SHOWN IN TABLE
)NSTABILITY
4HESE COMPRISE THE FOLLOWING
s
,OAD AND SHIFT MANOEUVRE
s
!NTERIOR APPREHENSION TEST
s
2ELOCATION TEST FOR ANTERIOR INSTABILITY
s
3ULCUS TEST
!LL ARE EXPLAINED IN SECTION AND PLACED IN BROADER CONTEXT IN TABLE 4HEY MAY BE REGARDED AS
REDUNDANT IN THE AGE GROUP PROVIDED THERE IS NO HISTORY OF MAJOR TRAUMA
#ONTRACTILE FUNCTION
2OTATOR CUFF
4EST THE RELEVANT MUSCLES ISOMETRICALLY AGAINST MAXIMAL RESISTANCE 4HE '$' RECOMMENDS THAT A
HAND
HELD DYNAMOMETER BE CONSIDERED FOR QUANTIFYING CONTRACTILE FORCE 0AIN IMPLICATES THE CUFF
AND CUFF TEARS ARE ASSOCIATED WITH WEAKNESS )N THE CASE OF PARTIAL TEARS THIS IS PROBABLY DUE TO PAIN
INHIBITION 4HE MOST SPECIFIC TESTS FOR THE CUFF MUSCLES ARE
s
4HE @FULL CAN TEST FOR SUPRASPINATUS
s
2ESISTED LATERAL ROTATION FROM A POSITION OF MEDIAL ROTATION FOR INFRASPINATUS
s
4HE @'ERBER PUSH WITH FORCE TEST FOR SUBSCAPULARIS
4HESE TESTS WHICH ARE DEFINED IN SECTION ARE PERFORMED IN NON NEUTRAL JOINT POSITIONS SO IT IS
IMPORTANT TO ENSURE THAT THE POSITIONS ARE PAINLESS BEFORE TESTING
)F A CUFF TEAR IS SUSPECTED ADDITIONAL TESTS MAY BE CONDUCTED 4HESE INCLUDE
s
4HE DROP ARM TEST FOR SUPRASPINATUS POSITIVE IF THE PATIENT IS UNABLE TO SLOWLY LOWER HIS OR HER
AFFECTED ARM FROM ELEVATION DUE TO PAIN
s
4HE LIFT OFF TEST FOR SUBSCAPULARIS POSITIVE IF THE PATIENT CANNOT LIFT THE DORSUM OF HIS OR HER HAND
FROM THE SMALL OF THE BACK
"ICEPS
"ICEPS SHOULD ALSO BE EVALUATED 4HIS MAY BE DONE BY MEANS OF
s
)SOMETRIC FLEXION AT ELBOW FLEXION #YRIAX
s
9ERGASONS TEST ISOMETRIC SUPINATION AT OF ELBOW FLEXION #ALIS ET AL
s
3PEEDS TEST FLEXION OF A STRAIGHT SUPINATED ARM FROM AGAINST RESISTANCE #ALIS ET AL
4HE SENSITIVITY AND SPECIFICITY OF 9ERGASONS AND 3PEEDS TEST HAVE BEEN EVALUATED IN RELATION TO 3)3
USING SUBACROMIAL LOCAL ANAESTHESIA AS A GOLD STANDARD BUT THIS SHEDS LITTLE LIGHT ON THEIR USEFULNESS AS
SPECIFIC INDICATORS OF BICEPS PATHOLOGY #ALIS ET AL
)MPINGEMENT TESTS
4HE FOLLOWING TESTS ARE OF VALUE !LL ARE EXPLAINED IN SECTION AND PUT INTO BROADER CONTEXT IN
TABLE
s
0AINFUL ARC
s
.EERS TEST
s
(AWKINS +ENNEDY TEST
)F A PAINFUL ARC IS POSITIVE 3)3 IS VERY LIKELY #ONVERSELY IF THE .EERS AND (AWKINS +ENNEDY TESTS ARE
NEGATIVE IMPINGEMENT IS VERY UNLIKELY
s
)NTERNAL ROTATION RESISTANCE STRENGTH TEST FOR INTERNAL IMPINGEMENT
4HIS IS A SENSITIVE AND SPECIFIC MEANS OF DIFFERENTIATING INTRA ARTICULAR IMPINGEMENT FROM 3)3
0ALPATION
)F LOCALISED TREATMENT IS CONTEMPLATED PALPATION FOR TENDERNESS SHOULD BE CONDUCTED POSITIONING THE
PATIENT SO AS TO MAXIMALLY EXPOSE THE TENDONS SEE SECTION
4ABLE $IFFERENTIAL DIAGNOSIS A SUMMARY OF MOVEMENT IMPINGEMENT AND INSTABILITY TESTS
#ONDITION
3IGN
3)3
)NSTABILITY
03')
3,!0
#APSULITIS
!#*
ARTHRITIS
0AINFUL
ACTIVE
!RC
0OSSIBLE
0OSSIBLE
0OSSIBLE
%LEVATION
0OSSIBLE
0OSSIBLE
0OSSIBLE
-EDIAL
0OSSIBLE
ROTATION
0OSSIBLE
0OSSIBLE
,ATERAL
ROTATION
)N THE
0OSSIBLE
(ORIZONTAL
ADDUCTION 0OSSIBLE
.A
,IMITATION
OF ACTIVE
%LEVATION
0OSSIBLE
0OSSIBLE
)N A CUFF
TEAR ACTIVE
ELEVATION
MAY NOT BE
ACHIEVABLE
,ATERAL
ROTATION
-EDIAL
ROTATION
0OSSIBLE
0OSSIBLE
,IMITATION
OF PASSIVE
%LEVATION
0OSSIBLE
0OSSIBLE
,ATERAL
ROTATION
-EDIAL
ROTATION
0OSSIBLE
0OSSIBLE
(ORIZONTAL
ADDUCTION 0OSSIBLE
0OSSIBLE
APPREHENSION
TEST POSITION
!S FOR 3)3
.A
#ONDITION
3IGN
3)3
)NSTABILITY
03')
3,!0
#APSULITIS
!#*
ARTHRITIS
0OSITIVE
.EER
0OSSIBLE
0OSSIBLE
.A
.A
(AWKINS
+ENNEDY
0OSSIBLE
0OSSIBLE
.A
.A
,OAD AND
SHIFT
0OSSIBLE
0OSSIBLE
0OSSIBLE
.A
!PPREHENSION
0OSSIBLE
.A
.A
2ELOCATION
0OSSIBLE
.A
.A
3ULCUS TEST
0OSSIBLE
0OSSIBLE
.A
.A
)2234
.A
.A
$IAGNOSTIC IMAGING
2ADIOGRAPHS
!NTERO
POSTERIOR RADIOGRAPHS ENABLE VISUALISATION OF
s
#ALCIFIC TENDINITIS "IGLIANI AND ,EVINE
s
!CROMIAL MORPHOLOGY -ORRISON ET AL
4HEY ARE OF VERY LIMITED VALUE IN STAGE ) IMPINGEMENT (AWKINS AND !BRAMS )N MORE ADVANCED
CASES THEY MAY ENABLE VISUALISATION OF
s
3UBCHONDRAL CYSTS OR SCLEROSIS OF THE GREATER TUBEROSITY POSSIBLY WITH CORRESPONDING SCLEROSIS OR
SPUR FORMATION AT THE ACROMION
s
/STEOARTHROSIS OF THE ACROMIOCLAVICULAR OR INDEED GLENOHUMERAL JOINT "IGLIANI AND ,EVINE
s
4HE ACROMIOHUMERAL INTERVAL )N A NORMAL SHOULDER THIS MEASURES nMM ! REDUCTION MAY
INDICATE A CUFF TEAR -AGEE
5LTRASOUND MAGNETIC RESONANCE IMAGING -2) AND MAGNETIC RESONANCE
ARTHROGRAPHY -2!
$INNES ET AL HAVE SYSTEMATICALLY REVIEWED STUDIES INTO THE DIAGNOSTIC ACCURACY OF ULTRASOUND -2)
AND -2! FOR ROTATOR CUFF TEARS 4HEY CONCLUDE THAT BOTH ULTRASOUND AND -2) MAY BE ABLE TO PROVIDE
CONVINCING EVIDENCE OF FULL THICKNESS TEARS BUT THAT THE IMPLICATIONS OF NEGATIVE RESULTS ARE EQUIVOCAL
7ITH RESPECT TO PARTIAL TEARS THOUGH BETTER THAN -2) ULTRASOUNDS ACCURACY IS PROBABLY POOR $INNES ET
AL TENTATIVELY REPORT THAT -2! MAY BE ACCURATE IN THE DETECTION OF BOTH FULL AND PARTIAL THICKNESS
TEARS BUT THAT FURTHER EVIDENCE IS REQUIRED TO CONFIRM THIS AND CAUTION THAT ANY POTENTIAL BENEFITS MUST
BE BALANCED AGAINST ITS INVASIVENESS AND POTENTIAL DISCOMFORT 0HYSICAL EXAMINATION CLEARLY REMAINS
RELEVANT
%VIDENCE SUMMARY
s
2ADIOGRAPHS ENABLE VISUALISATION OF CALCIFIC DEPOSITS
s
2ADIOGRAPHS ARE OF LIMITED VALUE IN STAGE ) IMPINGEMENT BUT MAY SHOW BONY CHANGES IN THE LATER
STAGES
s
0OSITIVE IDENTIFICATIONS OF FULL THICKNESS TEARS BY ULTRASOUND AND -2) ARE PROBABLY RELIABLE
s
.EITHER ULTRASONOGRAPHY NOR -2) IS ACCURATE AT DETERMINING THE PRESENCEABSENCE OF PARTIAL
THICKNESS TEARS
s
-2! IS INVASIVE AND ITS ACCURACY IS UNCERTAIN
&OR EXPLANATION OF ABSENCE OF LEVEL OF EVIDENCE SEE PARAGRAPH
2EFERENCES SUPPORTING 3ECTIONS n
!MERICAN !CADEMY OF /RTHOPAEDIC 3URGEONS !!/3 CLINICAL GUIDELINE ON SHOULDER PAIN
2OSEMONT ), !MERICAN !CADEMY OF /RTHOPAEDIC 3URGEONS P
"AGG 3$ AND &ORREST 7* ! BIOMECHANICAL ANALYSIS OF SCAPULAR ROTATION DURING ARM ABDUCTION IN
THE SCAPULAR PLANE !MERICAN *OURNAL OF 0HYSICAL -EDICINE AND 2EHABILITATION n
"IGLIANI ,5 AND ,EVINE 7. #URRENT CONCEPTS REVIEW SUBACROMIAL IMPINGEMENT SYNDROME
*OURNAL OF "ONE AND *OINT 3URGERY
! n
"HMER !3 3TAFF 0( AND "ROX *) 3UPERVISED EXERCISES IN RELATION TO ROTATOR CUFF DISEASE
IMPINGEMENT SYNDROMES ) AND )) A TREATMENT REGIMEN AND ITS RATIONALE 0HYSIOTHERAPY 4HEORY AND
0RACTICE n
"RINKMANN *2 #OMPARISON OF A HAND
HELD AND FIXED DYNAMOMETER IN MEASURING STRENGTH OF
PATIENTS WITH NEUROMUSCULAR DISEASE *OURNAL OF /RTHOPAEDIC AND 3PORTS 0HYSICAL 4HERAPY
"UNKER 4 &ROZEN SHOULDER UNRAVELLING THE ENIGMA !NNALS OF THE 2OYAL #OLLEGE OF 3URGEONS OF
%NGLAND n
#ALIS - !KGN + "IRTANE - +ARACAN ) #ALIS ( AND 4ZN & $IAGNOSTIC VALUES OF CLINICAL
DIAGNOSTIC TESTS IN SUBACROMIAL IMPINGEMENT SYNDROME !NNALS OF 2HEUMATIC $ISEASE n
)NCLUDED IN THE SYSTEMATIC REVIEW BY $INNES ET AL
#AVALLO 2* AND 3PEER +0 3HOULDER INSTABILITY AND IMPINGEMENT IN THROWING ATHLETES -EDICINE
3CIENCE IN 3PORTS %XERCISE 3UPPLEMENT n
#RAWFORD (* AND *ULL '! 4HE INFLUENCE OF THORACIC POSTURE AND MOVEMENT ON THE RANGE OF
ARM ELEVATION 0HYSIOTHERAPY 4HEORY AND 0RACTICE n
#ULHAM % AND 0EAT - &UNCTIONAL ANATOMY OF THE SHOULDER COMPLEX *OURNAL OF /RTHOPEDIC AND
3PORTS 0HYSICAL 4HERAPY n
#YRIAX *( 4EXTBOOK OF /RTHOPAEDIC -EDICINE 6OLUME ) $IAGNOSIS OF 3OFT 4ISSUE ,ESIONS
/XFORD "ALLIERE 4INDALL TH EDN
#YRIAX *( AND #YRIAX 0* )LLUSTRATED -ANUAL OF /RTHOPAEDIC -EDICINE /XFORD "UTTERWORTH
(EINEMANN ND EDN
$INNES * ,OVEMAN % -C)NTYRE , AND 7AUGH . 4HE EFFECTIVENESS OF DIAGNOSTIC TESTS FOR
THE ASSESSMENT OF SHOULDER PAIN DUE TO SOFT TISSUE DISORDERS A SYSTEMATIC REVIEW (EALTH 4ECHNOLOGY
!SSESSMENT
$I6ETA * 7ALKER -, AND 3KIBINSKI " 2ELATIONSHIP BETWEEN PERFORMANCE OF SELECTED SCAPULAR
MUSCLES AND SCAPULAR ABDUCTION IN STANDING SUBJECTS 0HYSICAL 4HERAPY n
$OODY 3' &REEDMAN , AND 7ATERLAND *# 3HOULDER MOVEMENTS DURING ABDUCTION IN THE
SCAPULAR PLANE !RCHIVES OF 0HYSICAL -EDICINE AND 2EHABILITATION /CTOBER n
$VIR : 'RADE IN MANUAL MUSCLE TESTING THE PROBLEM WITH SUBMAXIMAL STRENGTH ASSESSMENT
#LINICAL 2EHABILITATION n
&INCH % "ROOKS $ 3TRATFORD 07 AND -AYO .% 0HYSICAL 2EHABILITATION /UTCOME -EASURES !
'UIDE TO %NHANCED #LINICAL $ECISION -AKING "ALTIMORE ,IPPINCOTT 7ILLIAMS AND 7ILKINS ND EDN
&UKUDA ( (AMADA + .AKAJIMA 4 9AMADA . 4OMONAGA ! 'OTO - 0ARTIAL THICKNESS TEARS
OF THE ROTATOR CUFF A CLINICOPATHOLOGICAL VIEW BASED ON SURGICALLY VERIFIED CASES )NT /RTHOP
n
'IBSON -( 'OEBEL '6 *ORDAN 4- +EGERREIS 3 AND 7ORRELL 47 ! RELIABILITY STUDY OF
MEASUREMENT TECHNIQUES TO DETERMINE STATIC SCAPULAR POSITION *OURNAL OF /RTHOPAEDIC AND 3PORTS
0HYSICAL 4HERAPY n
'REEN 3 "UCHBINDER 2 &ORBES ! AND "ELLAMY . ! STANDARDISED PROTOCOL FOR MEASUREMENT
OF THE RANGE OF MOVEMENT OF THE SHOULDER USING THE PLURIMETER 6 INCLINOMETER AND ASSESSMENT OF ITS
INTRARATER AND INTERRATER RELIABILITY !RTHRITIS #ARE AND 2ESEARCH n
'REENFIELD " #ATLIN 0! #OATES 07 'REEN % -C$ONALD ** AND .ORTH # 0OSTURE IN PATIENTS
WITH SHOULDER OVERUSE INJURIES AND HEALTHY INDIVIDUALS *OURNAL OF /RTHOPAEDIC AND 3PORTS 0HYSICAL
4HERAPY n
(ANDELBERG & 7ILLEMS 3 3HABPOUR - (USKIN *0 AND +UTA * 3,!0 LESIONS A RETROSPECTIVE
MULTICENTER STUDY !RTHROSCOPY n
(ARRYMAN $4 3IDLES *! #LARK *- -C1UADE +* 'IBB 4$ AND -ATSEN &- 4RANSLATION OF THE
HUMERAL HEAD ON THE GLENOID WITH PASSIVE GLENOHUMERAL MOTION *OURNAL OF "ONE AND *OINT 3URGERY
! n
(AURY * /TTL ' )MHOFF ! AND -ERL 4 )NCIDENCE OF 3,!0 LESIONS LABRUM LESIONS AND ROTATOR
CUFF DISEASE IN CADAVERIC SHOULDERS n -2 ARTHROGRAPHY COMPARED TO ARTHROSCOPIC FINDINGS *OURNAL OF
"ONE *OINT 3URGERY "R
" 3UPPLEMENT ))
(AWKINS 2* !BRAMS *3 @)MPINGEMENT SYNDROME IN THE ABSENCE OF ROTATOR CUFF TEAR STAGES
AND 4HE /RTHOPEDIC #LINICS OF .ORTH !MERICA n
(AWKINS 2* AND +ENNEDY *# )MPINGEMENT SYNDROME IN ATHLETES !MERICAN *OURNAL OF 3PORTS
-EDICINE n
(AYES + 7ALTON * 3ZOMOR :, AND -URRELL '!# 2ELIABILITY OF FIVE METHODS FOR ASSESSING
SHOULDER RANGE OF MOTION !USTRALIAN *OURNAL OF 0HYSIOTHERAPY n
(ENK *! DE 'ROOT * 6AN 7OENSEL 77,- AND 2OZING 0- %LECTROMYOGRAPHY OF SHOULDER
MUSCLES IN RELATION TO FORCE DIRECTION *OURNAL OF 3HOULDER AND %LBOW 3URGERY n
)TOI % -IAGAWA ( 3ATO 4 3ATO + AND 4ABATA 3 )SOKINETIC STRENGTH AFTER TEARS OF THE
SUPRASPINATUS TENDON *OURNAL OF "ONE AND *OINT 3URGERY
"R n
)TOI % +IDO 4 3ANO ! 5RAYAMA - AND 3ATO + 7HICH IS MORE USEFUL THE FULL CAN TEST
OR THE EMPTY CAN TEST IN DETECTING THE TORN SUPRASPINATUS TENDON !MERICAN *OURNAL OF 3PORTS
-EDICINE n
*OBE #- 0OSTERIOR SUPERIOR GLENOID IMPINGEMENT EXPANDED SPECTRUM !RTHROSCOPY THE
*OURNAL OF !RTHROSCOPIC AND 2ELATED 3URGERY n
+ELLY "4 +ADRMAS 72 AND 3PEER +0 4HE MANUAL MUSCLE EXAMINATION FOR ROTATOR CUFF STRENGTH
AN ELECTROMYOGRAPHIC INVESTIGATION !MERICAN *OURNAL OF 3PORTS -EDICINE n
+ENDALL (/ AND -C#REARY %+ -USCLES 4ESTING AND &UNCTION "ALTIMORE 7ILLIAMS AND 7ILKINS
RD EDN
+ESSEL , AND 7ATSON - 4HE PAINFUL ARC SYNDROME CLINICAL CLASSIFICATION AND A GUIDE TO
MANAGEMENT *OURNAL OF "ONE AND *OINT 3URGERY
" n
+IBLER 7" 4HE ROLE OF THE SCAPULA IN ATHLETIC SHOULDER FUNCTION !MERICAN *OURNAL OF 3PORTS
-EDICINE n
,ITAKER $ 0OIRO - %L "ILBEISI ( AND "REMS * 2ETURNING TO THE BEDSIDE USING THE HISTORY AND
PHYSICAL EXAMINATION TO IDENTIFY ROTATOR CUFF TEARS *OURNAL OF THE !MERICAN 'ERIATRICS 3OCIETY
n )NCLUDED IN THE SYSTEMATIC REVIEW BY $INNES ET AL
,IU 3( (ENRY -( .UCCION 3 3HAPIRO -3 AND $OREY & $IAGNOSIS OF GLENOID LABRAL TEARS
A COMPARISON BETWEEN MAGNETIC RESONANCE IMAGING AND CLINICAL EXAMINATIONS !MERICAN *OURNAL OF
3PORTS -EDICINE n
,UDEWIG 0- AND #OOK 4- !LTERATIONS IN SHOULDER KINEMATICS AND ASSOCIATED MUSCLE ACTIVITY IN
PEOPLE WITH SYMPTOMS OF SHOULDER IMPINGEMENT 0HYSICAL 4HERAPY n
-AC$ONALD 0" #LARK 0 AND 3UTHERLAND + !N ANALYSIS OF THE DIAGNOSTIC ACCURACY OF THE
(AWKINS AND .EER SUBACROMIAL IMPINGEMENT SIGNS *OURNAL OF 3HOULDER AND %LBOW 3URGERY n
)NCLUDED IN THE SYSTEMATIC REVIEW BY $INNES ET AL
-AGAREY - AND *ONES - #LINICAL DIAGNOSIS AND MANAGEMENT OF MINOR SHOULDER INSTABILITY
!USTRALIAN 0HYSIOTHERAPY n
-AGEE $* /RTHOPAEDIC 0HYSICAL !SSESSMENT 0HILADELPHIA 7" 3AUNDERS
-AHAFFEY ", AND 3MITH 0! 3HOULDER INSTABILITY IN YOUNG ATHLETES !MERICAN &AMILY 0HYSICIAN
-AY AVAILABLE AT HTTPWWWAAFPORGAFPAPHTML
-ATSEN &! AND !RNTZ #4 3UBACROMIAL IMPINGEMENT IN THE SHOULDER 0HILADELPHIA 0! 3AUNDERS
n
-ATTINGLEY '% AND -ACKAREY 0* /PTIMAL METHODS FOR SHOULDER TENDON PALPATION A CADAVER
STUDY 0HYSICAL 4HERAPY n
-C#LURE 07 -ICHENER ,! 3ENNETT "* AND +ARDUNA !2 $IRECT DIMENSIONAL MEASUREMENT
OF SCAPULAR KINEMATICS DURING DYNAMIC MOVEMENTS IN VIVO *OURNAL OF 3HOULDER AND %LBOW 3URGERY
n
-ICHIELS ) AND 'REVENSTEIN * +INEMATICS OF SHOULDER ABDUCTION IN THE SCAPULAR PLANE ON THE
INFLUENCE OF ABDUCTION VELOCITY AND EXTERNAL LOAD #LINICAL "IOMECHANICS n
-INIACI ! AND 3ALONEN $ 2OTATOR CUFF EVALUATION IMAGING AND DIAGNOSIS /RTHOPEDIC #LINICS OF
.ORTH !MERICA n
-ORRISON $3 &ROGAMENI !$ AND 7OODWORTH 0 .ON OPERATIVE TREATMENT OF SUBACROMIAL
IMPINGEMENT SYNDROME *OURNAL OF "ONE *OINT 3URGERY ! n
.EER # )MPINGEMENT LESIONS #LINICAL /RTHOPAEDICS AND 2ELATED 2ESEARCH n
.EIERS , AND 7ORRELL 47 !SSESSMENT OF SCAPULAR POSITION *OURNAL OF 3PORT 2EHABILITATION
n
.EVIASER 2* .EVIASER 4* 4HE FROZEN SHOULDER DIAGNOSIS AND MANAGEMENT #LINICAL /RTHOPAEDICS
2ELATED 2ESEARCH n
/DOM #* 4AYLOR !" (URD #% AND $ENEGAR #2 -EASUREMENT OF SCAPULAR ASYMMETRY AND
ASSESSMENT OF DYSFUNCTION USING THE LATERAL SCAPULAR SLIDE TEST A RELIABILITY AND VALIDITY STUDY 0HYSICAL
4HERAPY n
/TIS *# *IANG # # 7ICKIEWICZ 4, 0ETERSON -'% 7ARREN 2& AND 3ANTNER 4* #HANGES IN THE
-OMENT !RMS OF THE 2OTATOR #UFF AND $ELTOID -USCLES WITH !BDUCTION AND 2OTATION *OURNAL OF "ONE
AND *OINT 3URGERY ! n
0ARKER 2$ AND 3EITZ 7( 3HOULDER IMPINGEMENTINSTABILITY OVERLAP SYNDROME *OURNAL OF THE
3OUTHERN /RTHOPAEDIC !SSOCIATION n
0HILLIPS "! ,O 3+ AND -ASTAGLIA &, -USCLE FORCE MEASURED USING BREAK TESTING WITH A
HAND HELD DYNAMOMETER IN NORMAL SUBJECTS AGED n YEARS !RCHIVES OF 0HYSICAL -EDICINE AND
2EHABILITATION
2IDDLE $, 2OTHSTEIN *- AND ,AMB 2, 'ONIOMETRIC RELIABILITY IN A CLINICAL SETTING SHOULDER
MEASUREMENTS 0HYSICAL 4HERAPY n
3HARKEY .! -ARDER 2! AND (ANSON 0" 4HE ENTIRE ROTATOR CUFF CONTRIBUTES TO ELEVATION OF THE
ARM *OURNAL OF /RTHOPAEDIC 2ESEARCH n
3OBUSH $# 3IMONEAU '# $IETZ +% ,EVENE *! 'ROSSMAN 2% AND 3MITH 7" 4HE ,ENNIE
TEST FOR MEASURING SCAPULAR POSITION IN HEALTHY YOUNG ADULT FEMALES A RELIABILITY AND VALIDITY STUDY
*OURNAL OF /RTHOPAEDIC AND 3PORTS 0HYSICAL 4HERAPY n
3TETSON 7" 3NYDER 3* AND +ARZEL 70 ,ONG TERM FOLLOW UP OF ISOLATED 3,!0 LESIONS OF THE
SHOULDER !RCHIVES OF THE !MERICAN !CADEMY OF /RTHOPAEDIC 3URGEONS n
4YLER 4& .ICHOLAS 3* 2OY 4 AND 'LEIM '7 1UANTIFICATION OF POSTERIOR CAPSULE TIGHTNESS AND
MOTION LOSS IN PATIENTS WITH SHOULDER IMPINGEMENT !M * 3PORTS -ED n
6ALADIE !, *OBE #- 0INK -- %KMAN %& AND *OBE &7 !NATOMY OF PROVOCATIVE TESTS FOR
IMPINGEMENT SYNDROME OF THE SHOULDER *OURNAL OF 3HOULDER AND %LBOW 3URGERY n
7ANG #
( -C#LURE 0 0RATT .% AND .OBILINI 2 3TRETCHING AND STRENGTHENING EXERCISES THEIR
EFFECT ON THREE DIMENSIONAL SCAPULAR KINEMATICS !RCH 0HYS -ED 2EHABIL n
9AMAKADO + 4HE TARGETING ACCURACY OF SUBACROMIAL INJECTION TO THE SHOULDER AN ARTHROGRAPHIC
EVALUATION !RTHROSCOPY n
:ASLAV +2 )NTERNAL ROTATION RESISTANCE STRENGTH TEST A NEW DIAGNOSTIC TEST TO DIFFERENTIATE INTRA
ARTICULAR PATHOLOGY FROM OUTLET .EER IMPINGEMENT SYNDROME IN THE SHOULDER *OURNAL OF 3HOULDER AND
%LBOW 3URGERY n )NCLUDED IN THE SYSTEMATIC REVIEW BY $INNES ET AL
:UCKERMAN *$ -IRABELLO 3# .EWMAN $ 'ALLAGHER - AND #UOMO & 4HE PAINFUL SHOULDER
PART )) )NTRINSIC DISORDERS AND IMPINGEMENT SYNDROME !MERICAN &AMILY 0RACTITIONER n
!IMS AND OBJECTIVES OF PHYSIOTHERAPY FOR
SHOULDER IMPINGEMENT SYNDROME
!IMS
s
4O MINIMISE PAIN
s
4O OPTIMISE FUNCTION
s
4O APPROPRIATELY REFER THOSE PATIENTS WHO ARE UNRESPONSIVE TO PHYSIOTHERAPY
/BJECTIVES
s
4O REDUCE SUBACROMIAL INFLAMMATION AND MANAGE PAIN
s
4O IMPROVE POSTURE
s
4O RESTORE RANGE STRENGTH STABILITY AND SCAPULOHUMERAL RHYTHM
s
4O IDENTIFY WHEN PATIENTS SHOULD BE REFERRED FOR AN ORTHOPAEDIC OPINION
%VIDENCE UNDERPINNING THE PHYSIOTHERAPY
MANAGEMENT OF 3)3 INCLUDING 3,!0 LESIONS
AND 03')
4HE CONSERVATIVE MANAGEMENT OF 3)3 3,!0 LESIONS AND 03') FOLLOWS SIMILAR LINES $IFFERENTIATION
BETWEEN THE PHYSIOTHERAPEUTIC MANAGEMENT OF 3)3 AND 3,!0 LESIONS WOULD BE UNREALISTIC BECAUSE OF
THE OVERLAP BETWEEN THESE CONDITIONS DISCUSSED IN 3ECTION AS WELL AS THE DIFFICULTY OF DIFFERENTIAL
DIAGNOSIS ! 3,!0 LESION MAY REMAIN UNSUSPECTED TILL REVEALED ARTHROSCOPICALLY IN AN @UNRESPONSIVE
SHOULDER /N THE OTHER HAND IT IS NOT KNOWN WHAT PROPORTION OF 3,!0 LESIONS DO RESPOND TO
CONSERVATIVE MANAGEMENT AND CONSEQUENTLY NEVER COME TO ARTHROSCOPIC DIAGNOSIS
2EDUCTION OF SUBACROMIAL INFLAMMATION AND PAIN MANAGEMENT
2EST AVOIDANCE OF AGGRAVATING ACTIVITIES AND NON STEROIDAL
ANTI INFLAMMATORY DRUGS
4HERE IS CONSENSUS THAT THE INITIAL MANAGEMENT OF 3)3 SHOULD INVOLVE RELATIVE REST AND AVOIDANCE OF
AGGRAVATING FACTORS PARTICULARLY OVERHEAD ACTIVITIES IN 3)3 OR IN 03') PAIN PROVOKING POSITIONS *OBE
4HIS SEEMS A REASONABLE PRINCIPLE BECAUSE AS PREVIOUSLY DISCUSSED PAIN INHIBITS SHOULDER MUSCLE
FUNCTION )N @IMPINGEMENTINSTABILITY OVERLAP SYNDROME 0ARKER AND 3EITZ ADVOCATE THE USE OF A
SLING FOR n DAYS INTERRUPTED ONLY BY TWICE DAILY PENDULAR EXERCISES BUT THIS SHOULD BE ADVISED WITH
CAUTION FOR FEAR OF PRECIPITATING PAIN RELATED ILLNESS BEHAVIOUR 3UCH STRICT REST SHOULD NEVER BE ADVISED
IN THE OVER S IN WHOM ADHESIVE CAPSULITIS MAY RESULT DISCUSSED BY 7INTERS ET AL A
!VOIDANCE OF AGGRAVATING ACTIVITIES IS USUALLY COMBINED WITH NON STEROIDAL ANTI INFLAMMATORY
MEDICATION .3!)$S AIMING TO HASTEN RESOLUTION OF PAIN AND INFLAMMATION EG *OBE -ORRISON
ET AL "UCHBINDER 'REEN AND 9OUD SYSTEMATICALLY REVIEWED 2#4S OF .3!)$S VERSUS PLACEBO
FOR ROTATOR CUFF TENDINITIS POOLING THE RESULTS OF THE TWO STUDIES WITH THE HIGHEST METHODOLOGICAL
SCORES 4HESE POOLED RESULTS SUGGESTED THAT .3!)$S WERE SUPERIOR IN IMPROVING THE RANGE OF ABDUCTION
WEIGHTED MEAN DIFFERENCE ;7-$= CONFIDENCE INTERVALS TO WHERE @ VALUES DENOTE
IMPROVEMENT 4HE IMPROVEMENT DID NOT DIFFER SIGNIFICANTLY ACCORDING TO THE .3!)$ USED NAPROXYN
OR DICLOFENAC 4HE 7-$ FOR PAIN WAS CONFIDENCE INTERVALS n TO WHERE @ VALUES
DENOTE DETERIORATION 4HE REVIEWERS URGE CAUTION IN THE INTERPRETATION OF THESE RESULTS HOWEVER SINCE
NEITHER OF THE 2#4S CONCERNED WAS STRONG METHODOLOGICALLY SCORING AND RESPECTIVELY
AND CONSIDERABLE MANIPULATION OF INADEQUATELY PRESENTED RESULTS WAS REQUIRED TO POOL THEIR DATA
3TUDIES INTO THE EFFICACY OF .3!)$S VERSUS ANALGESIA FOR 3)3 ARE LACKING (OWEVER MODERATE TO SEVERE
OSTEOARTHRITIC PAIN IS KNOWN TO BE MORE RESPONSIVE TO ORAL .3!)$S THAN TO PARACETAMOL 4OWHEED ET AL
AND EXTRAPOLATING FROM THESE RESULTS WOULD APPEAR TO JUSTIFY THE USE OF .3!)$S IN THE PRESENT
CONTEXT IN SPITE OF THE KNOWN ADVERSE EFFECTS AND ESPECIALLY SINCE ONLY SHORT COURSES n DAYS ARE
RECOMMENDED IN 3)3 2ODGERS AND #ROSBY 0ARKER AND 3EITZ -ORRISON ET AL
3PEED AND (AZLEMAN REPORTED WITHDRAWAL DUE TO .3!)$ RELATED ADVERSE EVENTS IN LESS THAN
OF PATIENTS IN NON RANDOMISED COMPARATIVE STUDIES FOR SHOULDER PAIN RISING TO IN 2#4S 4HE
EVENTS WERE MAINLY GASTROINTESTINAL SYMPTOMS SKIN RASH HEADACHE OR DIZZINESS THERE WAS NO EVIDENCE
THAT THEIR NATURE OR SEVERITY VARIED IN RELATION TO THE PARTICULAR ANALOGUE USED
!T THE TIME OF WRITING IT IS MEDICO LEGALLY INAPPROPRIATE FOR A PHYSIOTHERAPIST TO RECOMMEND MEDICATION
DIRECTLY TO A PATIENT EVEN IF IT IS AVAILABLE OVER THE COUNTER 4HE PHYSIOTHERAPIST SHOULD SUGGEST THAT THE
PATIENT DISCUSSES MEDICATION WITH HIS OR HER MEDICAL PRACTITIONER OR APPROACH THE PRACTITIONER ON THE
PATIENTS BEHALF
/NE MODERATE QUALITY 2#4 HAS SHOWN THAT PERI ARTICULAR INJECTION OF TENOXICAM VERSUS PLACEBO BENEFITS
THE PAIN AND STIFFNESS OF ROTATOR CUFF TENDINITIS )TZKOVITCH ET AL
%VIDENCE SUMMARY
s
s
s
,EVEL
2ELATIVE REST AND AVOIDANCE OF AGGRAVATING ACTIVITIES ARE BENEFICIAL IN THE
EARLY MANAGEMENT OF 3)3 ALLOWING PAIN AND INFLAMMATION TO SETTLE
)))
!BSOLUTE REST IS VERY RARELY NECESSARY AND RISKS PRECIPITATING PAIN RELATED
ILLNESS BEHAVIOUR AND ADHESIVE CAPSULITIS
)6
4HE POTENTIAL BENEFITS OF A SHORT n DAY COURSE OF .3!)$S OUTWEIGH
THE RISKS
)A
2ECOMMENDATION
'RADE
2EST
s
s
)NITIALLY RELATIVE REST SHOULD BE RECOMMENDED OVERHEAD OR OTHER
AGGRAVATING ACTIVITIES SHOULD BE AVOIDED IN PARTICULAR
"
!BSOLUTE REST SHOULD BE AVOIDED
.3!)$S
s
4HE BENEFITS OF A SHORT n DAY COURSE OF .3!)$S ARE LIKELY TO OUTWEIGH
THE RISKS )F SUCH MEDICATION HAS NOT BEEN PRESCRIBED THIS OPTION SHOULD
BE DISCUSSED WITH THE APPROPRIATE MEDICAL PRACTITIONER
#OLD THERAPY
4HE 0HILADELPHIA 0ANEL !LBRIGHT ET AL AND 'REEN ET AL FOUND INSUFFICIENT EVIDENCE TO
SPECIFICALLY CONFIRM OR REFUTE THE EFFICACY OF COLD THERAPY IN RELATION TO 3)3 BUT VAN DER (EIJDEN ET AL
REPORTED ONE NON
%NGLISH LANGUAGE 2#4 WHICH SHOWED IT TO BE INEFFECTIVE FOR SHOULDER PAIN
%VEN SO THIS MODALITY IS WIDELY ADVOCATED IN THE LITERATURE (AWKINS AND +ENNEDY AND (AWKINS
AND !BRAMS RECOMMEND COLD PACKS AFTER EXERCISE IN ORDER TO PREVENT REACTIVE INFLAMMATION
COLD PACKS ARE ALSO RECOMMENDED AS A MEANS OF REDUCING INFLAMMATION BY :UCKERMAN ET AL
2ODGERS AND #ROSBY AND $ONATELLI 4HE GENERAL CONSENSUS IS THAT COLD USUALLY ACHIEVES ITS
OPTIMAL EFFECTS n IN TERMS OF REDUCED PAIN BLOOD CIRCULATION AND METABOLISM n WITHIN n MINUTES
OF APPLICATION +ERR ET AL 4HIRTY MINUTES MAY BE NECESSARY IN THE OBESE BUT SHOULD NEVER BE
EXCEEDED SO AS TO AVOID DAMAGE TO SKIN OR DEEPER TISSUES INCLUDING NERVES )N VERY THIN PATIENTS
APPLICATIONS SHOULD BE LIMITED TO MINUTES )NTERPOSING A LAYER OF DAMP TOWELLING BETWEEN THE ICE
PACK AND THE PATIENTS SKIN REDUCES THE SMALL RISK OF ICE BURNS +ERR ET AL
0OTENTIALLY IRRITATIVE ACTIVITES SHOULD BE CAREFULLY AVOIDED WHILE COLD
INDUCED ANALGESIA PERSISTS ESPECIALLY
IN 3)3 SINCE ANIMAL STUDIES SUGGEST THAT COLD THERAPY MAY INCREASE RATHER THAN REDUCE OEDEMA
DISCUSSED BY +ERR ET AL /THER HAZARDS OF COLD PACKS ARE DOCUMENTED IN STANDARD TEXTBOOKS
EG ,OW AND 2EID
%VIDENCE SUMMARY
s
,EVEL
#OLD PACKS MAY HELP REDUCE THE PAIN AND INFLAMMATION OF 3)3 AND HELP RESOLVE
IRRITATION INDUCED BY EXERCISE
)6
4HERE IS CONSENSUS THAT COLD PACKS OPTIMAL EFFECTS ARE USUALLY ACHIEVED WITHIN
n MINUTES OF APPLICATION MINUTES MAY BE NEEDED TO ACHIEVE SATISFACTORY
RESULTS IN THE OBESE BUT TO REDUCE THE RISK OF TISSUE DAMAGE APPLICATIONS SHOULD
NEVER EXCEED THIS )N VERY THIN PATIENTS ICE SHOULD BE APPLIED FOR ONLY MINUTES
)6
s
!PPLICATION OF COLD PACKS PRIOR TO EXERCISE IS POTENTIALLY HARMFUL
))B
s
4HE HAZARDS OF COLD THERAPY ARE REVIEWED IN STANDARD TEXTBOOKS
)))
s
2ECOMMENDATION
'RADE
#OLD THERAPY
s
s
#OLD PACKS MAY BE USED TO REDUCE THE PAIN AND INFLAMMATION OF 3)3 AND TO
SETTLE IRRITATION POST
EXERCISE !PPLICATIONS VARY FROM A MAXIMUM OF MINUTES
WHICH MAY BE REQUIRED TO ACHIEVE SATISFACTORY DEEP COOLING RESULTS IN THE OBESE
TO A MINIMUM OF MINUTES IN THE VERY THIN IN WHOM LONGER APPLICATIONS
INCREASE THE RISK OF TISSUE DAMAGE
#OLD PACKS SHOULD NOT BE APPLIED PRIOR TO EXERCISE
"
(EAT THERAPY
.O 2#4S OF HEAT THERAPY WERE INCLUDED IN THE SYSTEMATIC REVIEWS BY THE 0HILADELPHIA 0ANEL !LBRIGHT ET
AL OR 'REEN ET AL (OWEVER VAN DER (EIJDEN ET AL CITE TWO STUDIES BOTH EVALUATING
INTERVENTIONS FOR PERIARTHRITIS
OF THE SHOULDER AND BOTH WITH NEGATIVE OUTCOMES /NE SHOWED NO
SIGNIFICANT DIFFERENCES BETWEEN REGIMES COMBINING EXERCISE WITH RESPECTIVELY HEAT INTRATENDINOUS
HYDROCORTISONE INJECTION AND INTRA
ARTICULAR HYDROCORTISONE INJECTION THE OTHER COMPARED DIATHERMY
HYDROCORTISONE INJECTION AND ANALGESIA EACH IN COMBINATION WITH EXERCISES AND REPORTED NO SIGNIFICANT
DIFFERENCES
4HE HAZARDS OF HEAT ARE DOCUMENTED IN STANDARD TEXTBOOKS EG ,OW AND 2EID
%VIDENCE SUMMARY
s
s
,EVEL
4HERE IS INSUFFICIENT EVIDENCE TO SUPPORT OR REFUTE THE USE OF HEAT THERAPY IN THE
MANAGEMENT OF 3)3
)A
4HE HAZARDS OF HEAT ARE DOCUMENTED IN STANDARD TEXTBOOKS
)))
2ECOMMENDATION
'RADE
(EAT
s
$UE TO INSUFFICIENT EVIDENCE NO RECOMMENDATION CAN BE MADE
.ONE
4HIS TERM WHICH HAS FALLEN INTO DISUSE IS DEFINED AS @)NFLAMMATION OF TISSUES AROUND A JOINT CAPSULE INCLUDING
TENDONS AND BURSA n /XFORD #ONCISE -EDICAL $ICTIONARY )T THEREFORE INCORPORATES 3)3
0ULSED ELECTROMAGNETIC FIELDS 0%-&
4WO 2#4S OF 0%-& HAVE BEEN SYSTEMATICALLY REVIEWED BY 'REEN ET AL THOUGH POOLING OF DATA
WAS NOT POSSIBLE )N ONE MINUTES DAILY 0%-& FOR SIX CONSECUTIVE DAYS SIGNIFICANTLY IMPROVED THE
PAIN AND STIFFNESS OF CALCIFIC TENDINITIS BOTH SHORT
TERM AND AT SIX WEEKS 4HE OTHER WEAKER STUDY
IN WHICH DATA WERE NOT ANALYSED QUANTITATIVELY YIELDED COMPATIBLE RESULTS 4HE SORENESS FOLLOWING
TREATMENT IS GREATER AFTER 0%-& THAN PLACEBO BUT THERE APPEARS TO BE NO LASTING ADVERSE EFFECT
REVIEWED BY 'REEN ET AL .O OTHER ADVERSE EFFECTS HAVE BEEN REPORTED
%VIDENCE SUMMARY
s
s
,EVEL
0%-& IMPROVES THE PAIN AND STIFFNESS OF CALCIFIC TENDINITIS IN THE SHORT
AND MEDIUM
TERM
)A
.O LASTING ADVERSE EFFECTS HAVE BEEN REPORTED
)6
2ECOMMENDATION
'RADE
0ULSED %LECTROMAGNETIC &IELDS
s
0%-& APPLIED FOR MINUTES ON CONSECUTIVE DAYS IS BENEFICIAL IN THE
TREATMENT OF CALCIFIC TENDINITIS BOTH SHORT
AND MEDIUM
TERM
4HOUGH IT IS ASSOCIATED WITH POST
TREATMENT SORENESS THIS IS ONLY TRANSITORY
5LTRASOUND
/NE ADEQUATE 2#4 OF ULTRASOUND FOR CALCIFIC TENDINITIS DEMONSTRATED SIGNIFICANT REDUCTION IN THE SIZE
OF THE DEPOSITS AND CLINICALLY IMPORTANT BENEFITS "UT VERY HIGH INTENSITIES WERE USED 7CM THE
TREATMENT WAS INTENSIVE TIMES WEEKLY AND THE BENEFITS n WHICH AT TWO MONTHS POST
INTERVENTION
INCLUDED PAIN REDUCTION RELATIVE TO THE CONTROL GROUP AND IMPROVEMENT IN FUNCTIONAL STATUS
n HAD DISAPPEARED AFTER NINE MONTHS REVIEWED BY !LBRIGHT ET AL AND 'REEN ET AL
! QUESTION THEREFORE ARISES AS TO THE COST
EFFECTIVENESS OF THE INTERVENTION ESPECIALLY IN RELATION TO ITS
POTENTIAL RISKS ! FURTHER TRIAL REVIEWED BY 'REEN ET AL INVESTIGATING THE EFFECT OF ACETIC ACID
IONTOPHORESIS PLUS ULTRASOUND SHOWED NO SIGNIFICANT BENEFIT IN THE TREATMENT OF CALCIFIC TENDINITIS
7ITH RESPECT TO GENERAL SHOULDER PAIN AND ROTATOR CUFF DISEASE 'REEN ET ALS META
ANALYSIS OF
TWO 2#4S SHOWED NO EVIDENCE THAT ULTRASOUND IS EFFECTIVE .OR DID TWO ADDITIONAL 2#4S OF ULTRASOUND
FOR SHOULDER PAIN WHICH THEY EXCLUDED FROM THE META
ANALYSIS BUT EVALUATED SEPARATELY 4HESE RESULTS
AGREE WITH !LBRIGHT ET ALS META
ANALYSES OF FOUR 2#4S AND THEIR ADDITIONAL EVALUATION OF COHORT
CONTROLLED STUDIES ##4S !LSO IN AGREEMENT IS VAN DER (EIJDEN ET ALS SYSTEMATIC EVALUATION OF
FOUR METHODOLOGICALLY ACCEPTABLE 2#4S 7ITH RESPECT TO SHOULDER PAIN THEREFORE ULTRASOUND APPEARS
TO BE EFFECTIVE ONLY FOR CALCIFIC TENDINITIS 0OSSIBLE ADVERSE EFFECTS OF THIS MODALITY WERE NOT CONSIDERED
IN ANY OF THE 2#4S EVALUATED 'REEN ET AL
%VIDENCE SUMMARY
s
,EVEL
2ELATIVE TO PLACEBO ULTRASOUND BENEFITS CALCIFIC TENDINITS SHORT AND MEDIUM TERM
!T NINE MONTHS THESE BENEFITS ARE NO LONGER EVIDENT
)A
s
%XCEPT FOR CALCIFIC TENDINITIS ULTRASOUND IS NOT BENEFICIAL IN 3)3
)A
s
.O 2#4S HAVE REPORTED ON ADVERSE EFFECTS
)A
s
(AZARDS ARE DOCUMENTED IN STANDARD TEXTBOOKS
)))
2ECOMMENDATION
'RADE
5LTRASOUND
s
s
)N CALCIFIC TENDINITIS HIGH INTENSITY 7CM CONTINUOUS ULTRASOUND
APPLIED DAILY FOR THREE WEEKS THEN ON ALTERNATE DAYS FOR THREE WEEKS GIVES SHORT
AND MEDIUM TERM BENEFIT
%XCEPT IN CALCIFIC TENDINITIS ULTRASOUND IS NOT RECOMMENDED FOR 3)3
,ASER
! META
ANALYSIS 'REEN ET AL OF THREE MODERATE
TO
GOOD QUALITY 2#4S COMPARING LASER TO PLACEBO
INDICATES THAT LASER IS NOT SIGNIFICANTLY SUPERIOR IN BRINGING ABOUT A GOOD OR EXCELLENT SHORT
TERM
RESULT IN 3)3 ! FOURTH 2#4 WHICH WAS EXCLUDED FROM THE META
ANALYSIS BUT CONSIDERED SEPARATELY
COMPARED LASER TO .3!)$S AND DEMONSTRATED SIGNIFICANT BENEFIT FOR LASER IN TERMS OF PAIN FUNCTION
AND RANGE OF MOTION /N CESSATION OF TREATMENT AT WEEKS THERE WAS A BETWEEN
MEDIAN DIFFERENCE
OF CMS CONFIDENCE INTERVALS ON A 6!3 FOR PAIN CMS
ON A 6!3 FOR FUNCTION AND
IN RANGE OF ABDUCTION "UT THIS 2#4 WAS ONLY OF MODERATE QUALITY AND OTHER SYSTEMATIC
REVIEWERS HAVE QUESTIONED ITS VALIDITY VAN DER (EIJDEN ET AL -OREOVER ITS LACK OF FOLLOW UP
MEANS THAT LONGER
TERM OUTCOMES ARE UNKNOWN 'REEN ET AL !DVERSE EFFECTS OF LASER HAVE NOT
BEEN INVESTIGATED
4RANSCUTANEOUS %LECTRICAL .ERVE 3TIMULATION 4%.3
"ASED ON TWO POORLY REPORTED ANDOR CONDUCTED 2#4S THERE IS NO EVIDENCE THAT 4%.3 IS MORE EFFECTIVE
IN REDUCING THE PAIN OF SHOULDER DISORDERS THAN ULTRASOUND OR OTHER ELECTRICAL METHODS REVIEWED BY
VAN DER (EIJDEN ET AL NO STUDIES MET THE INCLUSION CRITERIA OF THE 0HILADELPHIA 0ANEL !LBRIGHT
ET AL OR 'REEN ET AL .O ADVERSE EFFECTS HAVE BEEN REPORTED ,OW AND 2EID
%VIDENCE SUMMARY
,EVEL
s
4HE EVIDENCE IS CONTRADICTORY BUT ON BALANCE LASER DOES NOT APPEAR TO BENEFIT 3)3
)A
s
4%.3 DOES NOT APPEAR TO BENEFIT 3)3
)A
s
2#4S OF LASER HAVE NOT INVESTIGATED ADVERSE EFFECTS
)A
s
4HE POTENTIAL HAZARDS OF LASER ARE REVIEWED IN STANDARD TEXTBOOKS
)6
s
.O ADVERSE EFFECTS OF 4%.3 HAVE BEEN REPORTED
)6
"ASED ON WEAK PRIMARY EVIDENCE
2ECOMMENDATION
'RADE
,ASER AND 4RANSCUTANEOUS NERVE STIMULATION
s
$UE TO INSUFFICIENT EVIDENCE NO RECOMMENDATION CAN BE MADE
.ONE
$EEP TRANSVERSE FRICTION MASSAGE $4&-
4HIS TECHNIQUE ESSENTIALLY A LOCALISED SOFT TISSUE MOBILISATION IS DESCRIBED IN DETAIL ELSEWHERE #YRIAX
AND #YRIAX +ESSON AND !TKINS )N THE PRESENT CONTEXT IT COMPRISES MASSAGE APPLIED
AT RIGHT ANGLES TO THE FIBRES OF A SYMPTOMATIC TENDON WHICH IS MADE ACCESSIBLE AS DESCRIBED IN
SECTION ,IESDECK ET AL WHO CHARACTERISED THE INTERVENTIONS OF PHYSIOTHERAPISTS FOR
PATIENTS WITH SHOULDER PAIN REPORTED THAT $4&- WAS USED IN OF CASES OF TENDINITIS
#LINICAL EXPERIENCE INDICATES THAT $4&- RELIABLY INDUCES ANALGESIA THEREBY FACILITATING FUNCTION AND
THERE IS SOME WEAK EXPERIMENTAL EVIDENCE SUPPORTING THIS DE "RUIJN "ROSSEAU ET AL )T IS
ALSO BELIEVED TO OPTIMISE THE DISPOSITION OF COLLAGEN PREVENTING OR REDUCING TENDON THICKENING WHICH
WOULD BE A USEFUL CONTRIBUTION TO THE MANAGEMENT OF 3)3 +ESSON AND !TKINS )N CHRONIC CASES
WHERE IT IS APPLIED RELATIVELY FIRMLY THE HYPERAEMIA INDUCED MAY HELP DISPERSE CHEMICAL IRRITANTS +ESSLER
AND (ERTLING +ESSON AND !TKINS
4O AN EXTENT DEEP MASSAGES POSTULATED INFLUENCE ON COLLAGEN IS SUPPORTED BY ANIMAL WORK WHICH
ALSO DEMONSTRATES FUNCTIONAL BENEFITS $AVIDSON ET AL EVALUATED THE EFFECTS OF DEEP ALBEIT
LONGITUDINALLY ORIENTED MASSAGE ON COLLAGENASE
INDUCED ACHILLES TENDINOSIS IN RATS &OUR RANDOMLY
ALLOCATED GROUPS OF WERE STUDIED A A CONTROL GROUP B A TENDON
INJURED GROUP C A TENDON
INJURED GROUP BRIEFLY TREATED BY FIRM MASSAGE ON DAYS AND AND D A NON TENDON
INJURED GROUP SIMILARLY TREATED BY MASSAGE 'AIT ANALYSIS WAS UNDERTAKEN PRELIMINARILY AND ON DAYS
PRECEDING @MASSAGE DAYS 4HE ANIMALS WERE SACRIFICED AND THEIR TENDONS PREPARED FOR MICROSCOPY
DAYS AFTER THE LAST SESSION OF MASSAGE /NLY THE ANIMALS IN GROUP C SIGNIFICANTLY IMPROVED THEIR
RUNNING PERFORMANCE AFTER INJURY HAVING REGAINED THEIR ORIGINAL GAIT PATTERNS BY THE END OF THE
STUDY &IBROBLASTIC PROLIFERATION WAS SEEN IN GROUPS B AND C WITH THE LARGEST SIGNIFICANT INCREMENT
IN THE LATTER )N ORDER TO INITIATE COLLAGEN SYNTHESIS FIBROBLASTS MUST NOT ONLY PROLIFERATE BUT ALSO
ACTIVATE !CTIVATION WAS OBSERVED IN BOTH TENDON
INJURED GROUPS AS MIGHT BE EXPECTED BUT ALSO LESS
EXPECTEDLY IN THE MASSAGE
ONLY GROUP )NCREMENTS IN FIBRONECTIN A MOLECULE SYNTHESISED BY FIBROBLASTS
AND EPITHELIAL CELLS WHICH BINDS THE EXTRACELLULAR SUBSTANCE AND COLLAGEN WERE ALSO OBSERVED IN THE
TENDON
INJURED GROUPS AND THE MASSAGE
ONLY GROUP )T WOULD THEREFORE SEEM THAT MASSAGE IS OF ITSELF
A STIMULUS TO FIBROBLASTIC ACTIVATION AND FIBRONECTIN SYNTHESIS BOTH CRITICAL PROCESSES IN TENDON REPAIR
'ROUP C DID NOT DEMONSTRATE BENEFITS IN COLLAGEN DISPOSITION OVER GROUP B POSSIBLY BECAUSE OF THE
SHORT TIMEFRAME INVOLVED THOUGH THE AUTHORS SPECULATE THAT WITH EARLIER RESTORATION OF FUNCTION THE
STRESSES OF NORMAL USE WOULD PROMOTE REALIGNMENT SOONER
4HERE IS SOME DISPUTE OVER HOW EARLY $4&- MAY SAFELY BE STARTED FOLLOWING TISSUE INJURY 7ORK ON
RODENTS HAS SHOWN THAT DAYS ACTIVE MOBILISATION STARTING DAYS POST ACHILLES TENOTOMY ENHANCES
REPAIR WHEREAS A SIMILAR PERIOD OF MOBILISATION STARTED AT DAY IMPEDES IT %NWEMEKA ET AL
4HOUGH TENDON HEALING IN RODENTS DOES NOT DIRECTLY RELATE TO THAT IN HUMANS THIS HAS LED TO CONCERNS
THAT PASSIVE MOBILISATION TECHNIQUES AND $4&- IN PARTICULAR SHOULD NOT BE APPLIED EARLIER THAN THE TH
DAY FOLLOWING INJURY (UNTER
(OWEVER RATS ALLOWED TO SWIM POST ACHILLES TENOTOMY SUFFER NO DETRIMENTAL EFFECT -URRELL ET AL
!ND AGAIN IN RATS (ART AND $AHNERS HAVE SHOWN THAT FREE ACTIVITY FOLLOWING MEDIAL COLLATERAL
KNEE LIGAMENT TRANSECTION ENHANCES STABILITY PROVIDING THAT AT OPERATION THE SECONDARY STABILISING
STRUCTURES OF THE JOINT ARE LEFT INTACT THEREBY PROVIDING SOME MEASURE OF PROTECTION &URTHERMORE
MOBILISATION OF REPAIRED HUMAN FINGER TENDONS COMMENCING ON THE FIRST DAY POST OPERATIVELY APPEARS
TO BE BENEFICIAL PROVIDING IT IS PERFORMED GENTLY "ECKER ET AL 4AKEN TOGETHER THESE FINDINGS
DO SEEM TO SUGGEST THAT THE DEGREE OF STRESS APPLIED TO TISSUES IN THE EARLY STAGES OF REPAIR MIGHT BE
CRITICAL WITH STRONG STRESS BEING HARMFUL MINIMAL STRESS HARMLESS AND POTENTIALLY BENEFICIAL
4HERE IS NO SPECIFIC EVIDENCE OF $4&-S EFFICACY OR OTHERWISE FOR SHOULDER TENDINITIS +ESSON AND
!TKINS !LBRIGHT ET AL "ROSSEAU ET AL
%VIDENCE SUMMARY
,EVEL
s
$4&- IS COMMONLY USED THERAPEUTICALLY IN SHOULDER TENDINITIS
)))
s
$4&- IS BELIEVED TO OPTIMISE COLLAGEN DISPOSITION
)A
s
! RODENT TENDINOSIS MODEL SHOWS THAT DEEP MASSAGE SIGNIFICANTLY ENHANCES
FIBROBLAST PROLIFERATION FIBROBLAST ACTIVATION AND FIBRONECTIN SYNTHESIS AND
SIGNIFICANTLY ACCELERATES RESTORATION OF FUNCTION
)B
s
4HE TIMING FOR SAFE APPLICATION OF $4&- AFTER INJURY IE DAYS OR SOONER IS
DISPUTED BUT THE PRESSURE WITH WHICH IT IS APPLIED MAY BE CRITICAL
2ECOMMENDATION
))) )6
'RADE
$EEP TRANSVERSE FRICTION MASSAGE $4&-
s
$UE TO INSUFFICIENT EVIDENCE NO RECOMMENDATION CAN BE MADE
.ONE
3TEROID INJECTION
! NUMBER OF STUDIES INDICATE THAT STEROID MUST BE ACCURATELY PLACED IN ORDER TO ACHIEVE AN OPTIMAL
THERAPEUTIC EFFECT (OLLINGWORTH ET AL REVIEWED BY "UCHBINDER ET AL FOUND THE RESULTS
OF INJECTION INTO ANATOMICAL STRUCTURES IDENTIFIED USING #YRIAXS SYSTEM OF DIAGNOSIS #YRIAX
SUPERIOR TO TRIGGER POINT INJECTION FOR GENERAL SHOULDER PAIN %USTACE ET AL REPORTED SIMILARLY
SIGNIFICANT BENEFITS ONLY IN A SUBGROUP OF OF SUBACROMIAL INJECTIONS WHICH WERE ACCURATELY
TARGETED 4HE POOR @HIT RATE REFLECTS THE TECHNICAL DIFFICULTY INVOLVED IN SUBACROMIAL INJECTION AND
THIS POINT IS EMPHASISED BY 9AMAKADO WHO RADIOGRAPHICALLY EVALUATED THE OUTCOME OF
ATTEMPTED SUBACROMIAL INJECTIONS FOR 3)3 AND JUDGED ONLY OF THEM TO HAVE REACHED THE TARGET
SITE &URTHERMORE 0ARTINGTON AND "ROOME ASSESSED THE FATE OF INJECTIONS AIMED AT THE
SUBACROMIAL SPACE IN CADAVERIC SHOULDERS 4HESE REACHED THE TARGET IN CASES BUT IN SHOULDERS
OTHER STRUCTURES WERE INADVERTENTLY INFILTRATED INCLUDING THE ROTATOR CUFF IN SEVEN 4HE DISPARATE
DEGREES OF ACCURACY REPORTED IN THESE STUDIES MAY RELATE TO DIFFERENCES IN INDIVIDUAL INJECTORS SKILLS
AND UNFORTUNATELY IMPRECISE INJECTION TECHNIQUE MAY BE REINFORCED BY THE FACT THAT SOME PATIENTS
TRANSIENTLY IMPROVE IMMEDIATELY POST
INJECTION EVEN IF THIS HAS MISSED THE TARGET STRUCTURE 9AMAKADO
5NFORTUNATELY FEW STUDIES HAVE USED IMAGING TECHNIQUES TO CONFIRM INJECTION PLACEMENT )N
GENERAL THESE CONSIDERATIONS MAKE IT DIFFICULT TO DRAW CLEAR CONCLUSIONS FROM THE LITERATURE
"UCHBINDER ET AL POOLED DATA FROM TWO WELL
CONDUCTED STUDIES COMPARING STEROID INJECTION WITH
PLACEBO YIELDING A TOTAL OF PATIENTS PER INTERVENTION GROUP !DEJABO ET AL 0ETRI ET AL
"OTH STUDIES HAD USED SINGLE INJECTIONS OF THE STEROID ANALOGUE TRIAMCINILONE HEXACETONIDE n !DEJABO
ET AL AT THE VERY HIGH DOSAGE OF MG 0ETRI ET AL AT MG n AND INJECTION PLACEMENT
HAD BEEN CONFIRMED ULTRASONICALLY IN THE LATTER -ETA
ANALYSIS INDICATED A SMALL BENEFIT OF SUBACROMIAL
INJECTION OVER PLACEBO IN TERMS OF PAIN FUNCTION AND RANGE OF ABDUCTION AT WEEKS &IVE OTHER TRIALS
COMPARING SUBACROMIAL STEROID INJECTION WITH PLACEBO WERE CONSIDERED BUT COULD NOT BE POOLED THESE
VARIED IN TERMS OF QUALITY THE STEROID USED DOSAGE AND OUTCOME
!DEBAJO ET AL AND 0ETRI ET AL ALSO EVALUATED THE EFFICACY OF SUBACROMIAL INJECTION IN
RELATION TO .3!)$S "UCHBINDER ET AL SUBJECTED THESE DATA TO META
ANALYSIS WITH THOSE OF A THIRD
POORER QUALITY TRIAL WHOSE STEROID GROUP HAD RECEIEVED AN INJECTION OF MG TRIAMCINILONE ACETONIDE
REPEATED AFTER WEEKS IF NECESSARY 7HITE ET AL 4HE .3!)$ COMPARATORS WERE MG
DICLOFENAC TIMES A DAY FOR DAYS !DEBAJO ET AL MG NAPROXEN TWICE A DAY FOR DAYS
0ETRI ET AL AND MG INDOMETHACIN TIMES DAILY WITH A REPEAT PRESCRIPTION AFTER WEEKS IF
REQUIRED 7HITE ET AL .O BENEFIT OF SUBACROMIAL STEROID INJECTION OVER .3!)$ WAS DEMONSTRATED
WITH RESPECT TO IMPROVEMENT IN PAIN FUNCTION OR RANGE OF SHOULDER ABDUCTION AT FOUR OR SIX WEEKS
0ETRI ET AL USING THE DRUGS AND DOSAGES DESCRIBED ABOVE ADDITIONALLY COMPARED THE EFFICACY OF
STEROID INJECTION PLUS .3!)$S TO .3!)$S ALONE REVIEWED BY "UCHBINDER ET AL BUT SHOWED NO
ADDITIONAL BENEFIT FOR THE COMBINED THERAPY
"UCHBINDER ET AL CONCLUDE THAT EVIDENCE DOES SUPPORT THE USE OF SUBACROMIAL CORTICOSTEROID
INJECTION FOR ROTATOR CUFF DISEASE ALTHOUGH ITS EFFECT MAY BE SMALL AND NOT WELL MAINTAINED AND IT MAY
NOT BE SUPERIOR TO .3!)$S
7INTERS ET AL B PRODUCED A METHODOLOGICALLY POOR TRIAL REVIEWED BY 'REEN ET AL
EVALUATING TREATMENT FOR SYMPTOMS ARISING FROM SYNOVIAL STRUCTURES IN AND AROUND THE SHOULDER
)NTRA
ARTICULAR AND SUBACROMIAL INJECTIONS WERE COMPARED AVERAGE INJECTIONS OF MG TRIAMCINILONE
ACETONIDE TO MANIPULATIVE AND NON
MANIPULATIVE PHYSIOTHERAPY RESPECTIVELY 3IGNIFICANT BENEFIT
WAS DEMONSTRATED FOR INJECTION UP TO WEEKS (OWEVER A REVIEW AT YEARS SHOWED NO LONG
TERM
DIFFERENCE BETWEEN GROUPS
)T IS UNFORTUNATE THAT WITH FEW EXCEPTIONS THE RESEARCH LITERATURE DOES NOT REFLECT THE COMPLEMENTARY
WAYS IN WHICH DIFFERENT THERAPIES ARE USED CLINICALLY )N REALITY .3!)$S @PHYSIOTHERAPY AND STEROID
INJECTION ARE NOT NECESSARILY @STAND
ALONE APPROACHES ESPECIALLY NOW THAT INJECTION IS WITHIN
APPROPRIATELY TRAINED PHYSIOTHERAPISTS SCOPE OF PRACTICE )NDEED MOST AUTHORITIES VIEW STEROID INJECTION
AS AN ADJUNCT RATHER THAN AN ALTERNATIVE TO REHABILITATION EG 2ODGERS AND #ROSBY ESPECIALLY
WHERE 3)3 SECONDARY TO INSTABILITY IS CONCERNED +AMKAR ET AL "UT OPINION IS DIVIDED ON WHETHER
IT SHOULD ROUTINELY PRECEDE REHABILITATION OR BE RESERVED FOR CASES IN WHICH PAIN AND INFLAMMATION
HAMPER THE REHABILITATIVE PROCESS -OST FAVOUR THE LATTER CONSIDERING INJECTION TO BE INDICATED
VARIOUSLY AFTER @SEVERAL WEEKS !MERICAN !CADEMY OF /RTHOPAEDIC 3URGEONS @
WEEKS
:UCKERMAN ET AL OR SIMPLY IF THE IMPINGEMENT DOES NOT @IMPROVE WITH CONSERVATIVE TREATMENT
&ONGEMIE ET AL #IRCUMSTANCES MIGHT BE ENVISAGED WITH ACUTELY PAINFUL SHOULDERS IN WHICH
STEROID INJECTIONS ARE NECESSARY BEFORE ADEQUATE REHABILITATION CAN PROPERLY COMMENCE BUT THEIR USE
SHOULD BE TEMPERED BY AN AWARENESS THAT THEY ARE NOT RISK FREE )NJECTION MAY COMPROMISE THE TENSILE
STRENGTH OF COLLAGEN FOR UP TO DAYS AND SOME AUTHORITIES HAVE ALSO VOICED CONCERNS AS TO A LINK
BETWEEN STEROID INJECTIONS AND TENDON RUPTURE DISCUSSED BY +ESSON ET AL %FFORTS TO AVOID
INTRATENDINOUS INJECTION AND DIMINISH SUCH A RISK CANNOT BE GUARANTEED OF SUCCESS TO JUDGE FROM
0ARTINGTON AND "ROOMES CADAVERIC STUDY DISCUSSED ABOVE )N ANY EVENT NOT MORE THAN
THREE INJECTIONS SHOULD BE ADMINISTERED 3HANKWILER AND "URKHEAD AND IN VIEW OF COLLAGENS
POTENTIAL VULNERABILITY IT WOULD SEEM PRUDENT TO WITHHOLD RESISTIVE EXERCISE FOR A FORTNIGHT AFTER
EACH &OR A SUMMARY OF THE OTHER HAZARDS OF STEROID INJECTION SEE +ESSON ET AL /N BALANCE
A REASONABLE APPROACH WOULD SEEM TO BE ONE WHERE PHARMACOLOGICAL INTERVENTIONS ARE USED
COMPLEMENTARILY TO HELP FACILITATE THE EXERCISE AND MOBILISATION AT THE CORE OF THE REHABILITATION
EFFORT SEE SECTION 4HIS SHOULD MAXIMIZE CLINICAL BENEFITS WHILE AVOIDING THE HAZARDS OF EITHER
PROLONGED USE OF .3!)$S OR INJUDICIOUS STEROID INJECTION THERAPY
%VIDENCE 3UMMARY
s
3TEROID INJECTIONS BENEFIT 3)3 IN THE SHORT TERM
)A
s
3TEROID INJECTION IS TYPICALLY CONSIDERED AN ADJUNCT RATHER THAN AN ALTERNATIVE TO
REHABILITATION !LTHOUGH THIS VIEW IS NOT UNIVERSALLY HELD MOST AUTHORITIES ADVOCATE
INJECTION IF THE 3)3 IS UNRESPONSIVE TO SOME WEEKS CONSERVATIVE TREATMENT
)6
3TEROID INJECTIONS MAY COMPROMISE THE TENSILE STRENGTH OF COLLAGEN FOR UP
TO DAYS 2ESISTIVE EXERCISE SHOULD BE AVOIDED DURING THIS TIME
)))
3TUDIES INTO THE ACCURACY OF INJECTION PLACEMENT HAVE SHOWN DISAPPOINTING RESULTS
INCLUDING INADVERTENT INTRATENDINOUS INJECTION )N THE CLINICAL SETTING SUCH
PLACEMENT WOULD INCREASE THE RISK OF TENDON DAMAGE
)))
4HE SAME SUBACROMIAL SPACE SHOULD NOT BE INJECTED ON MORE THAN OCCASIONS
)6
s
s
s
,EVEL
2ECOMMENDATION
'RADE
3TEROID INJECTIONS
s
3TEROID INJECTIONS BENEFIT 3)3 IN THE SHORT TERM
s
)N VIEW OF THE ASSOCIATED RISKS IT IS SUGGESTED THAT STEROID INJECTIONS BE USED ONLY
AS NEEDED TO FACILITATE REHABILITATION )T IS ALSO SUGGESTED THAT NORMALLY UNLESS
SEVERE PAIN IS PRESENT A SEVERAL
WEEK TRIAL OF MORE CONSERVATIVE THERAPY SHOULD
PRECEDE THEIR USE
s
2ESISTIVE EXERCISE SHOULD BE WITHHELD FOR WEEKS FOLLOWING STEROID INJECTION
"
s
4HE SAME SUBACROMIAL SPACE SHOULD NOT BE INJECTED ON MORE THAN OCCASIONS
)MPROVEMENT OF POSTURE
&ORWARD
HEAD POSTURE HAS BEEN IMPLICATED IN 3)3 'REENFIELD ET AL 7HERE THIS IS PRESENT
THEREFORE AN EFFORT SHOULD BE MADE TO IMPROVE IT
%VIDENCE SUMMARY
s
4HERE IS AN ASSOCIATION BETWEEN FORWARD HEAD POSTURE AND SHOULDER PAIN
2ECOMMENDATION
,EVEL
))A
'RADE
)MPROVEMENT OF POSTURE
s
!N ATTEMPT TO CORRECT FORWARD HEAD POSTURE IS APPROPRIATE IN VIEW OF ITS
ASSOCIATION WITH SHOULDER PAIN
"
2ESTORATION OF RANGE STRENGTH STABILITY AND SCAPULOHUMERAL RHYTHM
4HE OUTLOOK FOR CONSERVATIVELY MANAGED 3)3 IS HOPEFUL )N THEIR DESCRIPTIVE STUDY -ORRISON ET AL
REPORTED AN EXCELLENT OR SATISFACTORY RESULT IN OF SHOULDERS WITH SIMPLE STRETCHES AND RESISTED
INTERNAL AND EXTERNAL ROTATION EXERCISES 4HE OUTCOME WAS BETTER IN YOUNGER PATIENTS IN THOSE WITH
ACUTE PROBLEMS AND IN THOSE WITH TYPE ) ACROMIONS
"ROX ET AL EVALUATED CASES OF 3)3 WHICH HAD PROVED RESISTANT TO STANDARD CONSERVATIVE
INTERVENTIONS IN AN 2#4 AND YEAR FOLLOW UP 0ATIENTS WERE RANDOMISED TO A DAILY REGIME OF SUPERVISED
LOW RESISTANCE EXERCISES PLUS EDUCATION ARTHROSCOPIC SURGERY OR DETUNED PLACEBO LASER AND BOTH
OF THE ACTIVE INTERVENTIONS YIELDED COMPARABLE FUNCTIONAL BENEFITS THAT WERE STATISTICALLY AND CLINICALLY
SIGNIFICANT RELATIVE TO THE PLACEBO 4HE EXERCISE REGIME COMPREHENSIVELY DESCRIBED IN A REVIEW ARTICLE
BY "ROX AND OTHERS "HMER ET AL INITIALLY USES SLING SUSPENSION TO NEUTRALISE GRAVITY 4HIS
ALLOWS RELAXED REPETITIVE MOVEMENTS SHOULDER ROTATION FIRST THEN ELEVATION THROUGH FLEXION AND FINALLY
THROUGH ABDUCTION BUILDING UP TO A TOTAL OF AN HOUR EACH DAY 4HE AIM IS TO RESTORE FULL PAINLESS
ACTIVE MOVEMENT AND SPECIAL ATTENTION IS PAID TO RETRAINING NORMAL INITIATION OF FLEXION AND ABDUCTION
TO AVOID MIGRATION OF THE HUMERAL HEAD 4O THESE ENDS EFFORTS ARE MADE TO RE ACTIVATE SUPRASPINATUS
2ECIPROCAL INHIBITION OF ANTAGONISTS MAY BE USED TO IMPROVE THE QUALITY OF MOVEMENT AND THE HUMERAL
HEAD IS PASSIVELY STABILISED CENTRALISED AS NECESSARY 7HEN THE RANGE OF PAINLESS ACTIVE MOVEMENT IS
IMPROVING AND NORMAL SCAPULOHUMERAL RELATIONSHIPS RESTORED LOW RESISTANCE IS GRADUALLY ADDED SUCH
THAT THREE SETS OF REPETITIONS ARE ACHIEVABLE FIRST BY ALTERING THE POINT OF SUSPENSION THEN BY
USING ELASTIC RESISTANCE BAND 0ROGRESSION IS TO PULLEY RESISTANCE IN SITTING THEN STANDING AND TO PUSH
UPS AGAINST A WALL /VER THE REGIMES THREE TO SIX MONTH DURATION "HMER ET AL RECOMMEND
DIMINISHING PHYSIOTHERAPIST SUPERVISION IN FAVOUR OF INCREASING PERFORMANCE OF THE EXERCISES AT
HOME "UT THE PROGRAMME IS LABOUR INTENSIVE AND ITS FEASIBILITY WOULD CLEARLY DEPEND ON EQUIPMENT
AVAILABILITY AND THE SUITABILITY OF BOTH THE PATIENT AND THE HOME ENVIRONMENT PARTICULARLY FROM A SAFETY
PERSPECTIVE
%XERCISE HAS ALSO BEEN SHOWN TO SIGNIFICANTLY IMPROVE RECOVERY FUNCTION AND RANGE OF ABDUCTION AT
ONE MONTH COMPARED TO CONTROLS IN A MIXED SHOULDER PAIN GROUP IN WHICH OF THE DIAGNOSES
WERE OF IMPINGEMENT 'INN ET AL !CTIVE INTERVENTIONS IN THIS STUDY WERE STRETCHING EXERCISES FOR
MUSCLES FOUND TO BE SHORT STRENGTHENING EXERCISES FOR MUSCLES FOUND TO BE WEAK AND MOTOR RETRAINING
AIMED AT RESTORING SCAPULOHUMERAL RHYTHM DURING THE PERFORMANCE OF UPPER LIMB TASKS 7ITHIN THIS
FRAMEWORK THE FREQUENCY AND DETAILS OF INTERVENTIONS WERE AT INDIVIDUAL PHYSIOTHERAPISTS DISCRETION
.O ORIGINAL RESEARCH APPEARS TO HAVE EVALUATED CLOSED KINETIC CHAIN ACTIVITIES SUCH AS RHYTHMIC
STABILISATION THOUGH THESE WOULD APPEAR TO HAVE A LOGICAL PLACE IN THE RESTORATION OF SCAPULOTHORACIC
AND SCAPULOHUMERAL FUNCTION AND ARE RECOMMENDED IN THE DESCRIPTIVE LITERATURE (ESS
3YSTEMATIC REVIEWERS HAVE INTERPRETED THE PRIMARY 2#4 EVIDENCE DIFFERENTLY !LBRIGHT ET AL
EXCLUDED 'INN ET AL FROM THEIR ANALYSIS ON GROUNDS OF NON
VALIDATED OUTCOMES LEADING THEM
TO A CONCLUSION OF OVERALL INSUFFICIENT EVIDENCE AS TO THE EFFICACY OF EXERCISES -ORE PRAGMATICALLY
PERHAPS 'REEN ET AL ACKNOWLEDGE METHODOLOGICAL FLAWS IN THE PRIMARY LITERATURE BUT CONSIDER
THAT JOINTLY THESE 2#4S CONSTITUTE AFFIRMATIVE IF WEAK EVIDENCE 7ITH REGARD TO THOSE STUDIES WHICH
PREDATE THEIR OWN REVIEW THIS OPINION IS SHARED BY VAN DER (EIJDEN ET AL
4WO 2#4S "ANG AND $EYLE #ONROY AND (AYES SHOW THAT THE PAIN OF 3)3 IS SIGNIFICANTLY
REDUCED AT n WEEKS BY ADDING MOBILISATION TO EDUCATION AND EXERCISES /NE OF THESE "ANG AND
$EYLE DEMONSTRATED ADDITIONAL BENEFITS IN TERMS OF RANGE OF MOTION STRENGTH AND FUNCTION
)N THIS STUDY EXERCISE COMPRISED PASSIVE STRETCHES FOR THE ANTERIOR AND POSTERIOR SHOULDER CAPSULE
AND MUSCULATURE AND SIX STRENGTHENING EXERCISES FOR THE MUSCLES OF THE SHOULDER GIRDLE AND ROTATOR
CUFF COMPRISING SHOULDER ELEVATION ROWING SHOULDER ELEVATION IN THE SCAPULAR PLANE AND HORIZONTAL
ABDUCTIONLATERAL ROTATION ALL USING RESISTANCE BANDS SITTING PUSH UPS AND PROTRACTION AGAINST GRAVITY
IN PRONE FOREARM
SUPPORTED LYING 4HESE STRENGTHENING EXERCISES HAD PREVIOUSLY BEEN SHOWN
IN ELECTROMYOGRAPHIC STUDIES TO COMPRISE THE MOST EFFECTIVE AND SUCCINCT SELECTION FOR OPTIMALLY
ACTIVATING
s
5PPER MIDDLE AND LOWER TRAPEZIUS
s
,EVATOR SCAPULAE
s
4HE RHOMBOIDS
s
0ECTORALIS MINOR
s
-IDDLE AND LOWER SERRATUS ANTERIOR -OSELEY ET AL
s
4HE ROTATOR CUFF PECTORALIS MAJOR
s
4HE THREE PARTS OF DELTOID 4OWNSEND ET AL
"ANG AND $EYLES MANUAL THERAPY GROUP ALSO RECEIVED PASSIVE PHYSIOLOGICAL OR ACCESSORY
MOBILISATION ADDRESSING ANY IDENTIFIED LIMITATION AT THE UPPER QUADRANT APPLIED ACCORDING TO STANDARD
PRINCIPLES -AITLAND AND ONE OR TWO ADDITIONAL HOME EXERCISES TO REINFORCE THESE
)N #ONROY AND (AYES STUDY ALL PATIENTS RECEIVED ACTIVE EXERCISES THREE TIMES WEEKLY 4HESE
INCLUDED PENDULAR EXERCISES POSTURAL CORRECTION PHYSIOLOGICAL STRETCHES AUTO ASSISTED FLEXION ROTATIONS
AND HORIZONTAL ADDUCTION WITHIN TOLERABLE LIMITS AND MUSCLE STRENGTHENING EXERCISES INCLUDING
SITTING PUSH UPS EMPHASISING THE CORRECTION OF POSTURAL IMBALANCE AND ISOMETRIC ROTATIONS )N THE
EXPERIMENTAL GROUP THE MOBILISATIONS WHICH WERE DERIVED FROM -AITLAND WERE SELECTED FROM
INFERIOR GLIDE WITH OR WITHOUT SHOULDER GIRDLE STABILISATION POSTERO ANTERIOR GLIDE AND ANTERO POSTERIOR
GLIDE ACCORDING TO THE DIRECTIONS IN WHICH ACCESSORY STIFFNESS WAS IDENTIFIED 4HE APPROACH SEEMS
FORMULAIC IN COMPARISON WITH THAT OF "ANG AND $EYLE BUT OFFERS A DISTINCT ADVANTAGE IN TERMS OF
REPRODUCIBILITY ESPECIALLY IN THE HANDS OF THE NON SPECIALIST PHYSIOTHERAPIST #ONROY AND (AYES
DID NOT DEMONSTRATE ANY IMPROVEMENT FOR ATTRIBUTES OTHER THAN PAIN BUT THIS MAY RELATE TO THE VERY
SMALL SAMPLE SIZE STUDIED PATIENTS IN EACH OF THE EXPERIMENTAL AND CONTROL GROUPS AND THEIR WORK
TAKEN IN CONJUNCTION WITH "ANG AND $EYLE PROVIDES SOME EVIDENCE THAT MOBILISATION AUGMENTS
THE EFFECTS OF EXERCISE IN 3)3 'REEN ET AL
%VIDENCE SUMMARY
s
s
,EVEL
! PROGRAMME OF EXERCISES TO RESTORE RANGE STRENGTH STABILITY AND SCAPULOHUMERAL
RHYTHM IS BENEFICIAL
)A
0ASSIVE MOBILISATION OF THE UPPER QUADRANT AUGMENTS THE BENEFICIAL EFFECTS OF
EXERCISE REDUCING PAIN AND INCREASING RANGE STRENGTH AND FUNCTION
)A
"ASED ON WEAK PRIMARY EVIDENCE
2ECOMMENDATION
'RADE
2ESTORATION OF RANGE STRENGTH STABILITY AND SCAPULOHUMERAL RHYTHM
s
0ASSIVE MOBILISATION OF THE UPPER QUADRANT AS NECESSARY AND APPLIED ACCORDING
TO STANDARD PRINCIPLES -AITLAND AUGMENTS THE BENEFICIAL EFFECTS OF EXERCISE
AND SHOULD BE UTILISED
! PROGRAMME OF EXERCISES TO RESTORE RANGE STRENGTH STABILITY AND SCAPULOHUMERAL
RHYTHM BENEFITS 3)3 ! SUGGESTED @CORE SET OF EXERCISES DERIVED FROM THE STRONGEST
AVAILABLE EVIDENCE IS DESCRIBED ILLUSTRATED AND GRADED BELOW 4HEY SHOULD
ALL BE PAINLESS
3CAPULOHUMERAL AND SCAPULOTHORACIC RHYTHMIC STABILISATION TRAINING MAY BE
INTRODUCED FROM AN EARLY STAGE UTILISING CLOSED KINETIC CHAIN WORK IN SITTING
STANDING IN FOUR
POINT KNEELING OR USING AN EXERCISE BALL SUCH THAT CONTROL IS
ACHIEVED IN PROGRESSIVELY LESS STABLE POSITIONS $URING THESE ACTIVITIES SCAPULAR
INSTABILITY SHOULD BE SCRUPULOUSLY AVOIDED FIGURES n
3TRENGTHENING EXERCISES MAY BE INTRODUCED IN THE FORM OF ISOTONIC MEDIAL AND
LATERAL ROTATION OF THE SHOULDER PERFORMED ELBOW
AT
SIDE -ORRISON ET AL
4HE PATIENT GENTLY GRIPS A TOWEL OR MAGAZINE BETWEEN ELBOW AND WAIST DURING
PERFORMANCE OF THE EXERCISE SO THAT CONTRACTION OF DELTOID IS DISCOURAGED
%LASTIC RESISTANCE BAND MAY BE USED TO PROVIDE LIGHT RESISTANCE AND THE PATIENT
BUILDS UP TO THREE SETS OF TEN REPETITIONS WITH TEN SECONDS REST AFTER EACH
REPETITION 7HEN THIS IS ACHIEVED THE RESISTANCE CAN BE INCREASED FIGURES n
"
s
3CAPULAR STABILITY WHEN PERFORMING STRENGTHENING EXERCISES IS PARAMOUNT
s
3TRETCHING EXERCISES MAY ALSO BE INTRODUCED AT AN EARLY STAGE 3TRENGTHENING
EXERCISES INCLUDE ANTERIOR AND POSTERIOR CAPSULAR STRETCH AS SHOWN IN
FIGURES n
"
s
s
s
2ECOMMENDATION
s
s
'RADE
7HEN MUSCULAR STABILITY IS IMPROVING AND AS THE SHOULDER BECOMES MORE
COMFORTABLE PROGRESSION MAY BE MADE TO MORE VIGOROUS STRENGTHENING
EXERCISES 4HE SET OF EXERCISES SHOWN IN FIGURES n HAS BEEN SHOWN
ELECTROMYOGRAPHICALLY TO MOST EFFICIENTLY ACTIVATE THE SCAPULAR AND SHOULDER
MUSCULATURE &OR THOSE EXERCISES WHICH DO NOT UTILISE BODY WEIGHT ELASTIC
RESISTANCE BAND PROVIDES A CONVENIENT AND ADJUSTABLE RESISTANCE
"
4HE EXERCISES ARE ALSO ILLUSTRATED IN !PPENDIX WHICH MAY BE COPIED FOR
DISTRIBUTION TO PATIENTS )T IS RECOMMENDED THAT THE EXERCISES ARE TAUGHT ON
A ONE
TO
ONE BASIS AND APPROPRIATE TEXT ADDED TO ENSURE THE PATIENTS FULL
UNDERSTANDING 4HE EXERCISES DESCRIBED REPRESENT A BASELINE AND SHOULD
NOT BE REGARDED AS AN EXHAUSTIVE LIST .UMEROUS OTHER EXERCISES WERE
IDENTIFIED IN THE LITERATURE AND ARE SUMMARISED IN !PPENDIX
&IGURE 3TABILISATION IN SITTING
&IGURE 3TABILISATION IN STANDING
3IT WITH PALMS RESTING ON SURFACE 'ENTLY
LEAN SIDEWAYS SO THE SHOULDER TAKES A LITTLE
WEIGHT 2EPEAT TO OPPOSITE SIDE
3TAND LEANING FORWARDS SLIGHTLY WITH
FOREARMS ON WALL SO THAT THE SHOULDERS
TAKE A LITTLE WEIGHT 3HIFT YOUR WEIGHT FROM
SIDE
TO
SIDE VERY SLIGHTLY
&IGURE 3TABILISATION IN
POINT KNEELING
3TARTING ON HANDS KNEES GENTLY LEAN FORWARD BACKWARD
SIDE
TO
SIDE
&IGURE 3TABILISATION WITH A BALL A HANDED B HANDED
+NEELING WITH HANDS ON BALL KEEPING ELBOWS STRAIGHT GENTLY LEAN FORWARD BACKWARD
SIDE TO SIDE
&IGURE -EDIAL ROTATION
&IGURE ,ATERAL ROTATION
7ITH ARM BENT TO O A TOWEL GENTLY HELD
UNDER THE ELBOW ROTATE THE ARM ACROSS THE
BODY USING A RESISTANCE BAND
7ITH ARM BENT TO O A TOWEL GENTLY HELD
UNDER THE ELBOW ROTATE THE ARM ACROSS THE
BODY USING A RESISTANCE BAND
&IGURE !NTERIOR CAPSULAR STRETCH
&IGURE 0OSTERIOR CAPSULAR STRETCH
2EST FOREARM AGAINST THE SIDE OF A DOORWAY
ELBOW BENT +EEPING UPRIGHT GENTLY LUNGE
FORWARD INTO OPENING OF DOORWAY UNTIL
STRETCH IS FELT
0LACE ARM ACROSS BODY GENTLY PUSH ELBOW
UNTIL STRETCH IS FELT
&IGURE &LEXION
3TARTING WITH ARM AT SIDE PULL RESISTANCE
BAND FORWARD UPWARD
&IGURE h2OWING
SHOULDER EXTENSION
0ULL RESISTANCE BAND BACKWARD BENDING THE
ELBOW IN A ROWING ACTION
&IGURE 3CAPTION IN MEDIAL
ROTATION
&IGURE (ORIZONTAL ABDUCTION WITH
LATERAL ROTATION
!N ACTION LIKE DRAWING A SWORD WITH THE
THUMB POINTING DOWNWARDS THROUGHOUT
5SE RESISTANCE BAND
+EEPING THE ARM HORIZONTAL MOVE IT FROM
FRONT
TO
BACK IN A HITCH
HIKING MOTION USING
A RESISTANCE BAND
&IGURE 0USH UPS
&IGURE 0RESS UPS PLUS
7ITH HANDS ON CHAIR ELBOWS STRAIGHT PUSH
DOWN THROUGH SHOULDERS TO LIFT BOTTOM
,IE RESTING ON FOREARMS LETTING BACK SAG
7ITHOUT LIFTING ELBOWS PRESS DOWN THROUGH
SHOULDERS
2ECOMMENDATIONS FOR PHYSIOTHERAPY
INTERVENTIONS IN 3)3 INCLUDING 3,!0 LESIONS
AND 03')
4HE FLOW CHART AT !PPENDIX GIVES AN OVERVIEW OF THE RECOMMENDATIONS FOR THE MANAGEMENT OF
SHOULDER IMPINGEMENT SYNDROME
2EDUCTION OF SUBACROMIAL INFLAMMATION AND PAIN MANAGEMENT
2ECOMMENDATION
'RADE
2EST
)NITIALLY RELATIVE REST SHOULD BE RECOMMENDED OVERHEAD OR OTHER AGGRAVATING
ACTIVITIES SHOULD BE AVOIDED IN PARTICULAR
"
!BSOLUTE REST SHOULD BE AVOIDED
.ON STEROIDAL ANTI INFLAMMATORY DRUGS .3!)$S
4HE BENEFITS OF A SHORT n DAY COURSE OF .3!)$S ARE LIKELY TO OUTWEIGH THE
RISKS )F SUCH MEDICATION HAS NOT BEEN PRESCRIBED THIS OPTION SHOULD BE
DISCUSSED WITH THE APPROPRIATE MEDICAL PRACTITIONER
#OLD THERAPY
#OLD PACKS MAY BE USED TO REDUCE THE PAIN AND INFLAMMATION OF 3)3 AND TO
SETTLE IRRITATION POST
EXERCISE !PPLICATIONS VARY FROM A MAXIMUM OF MINUTES
WHICH MAY BE REQUIRED TO ACHIEVE SATISFACTORY DEEP COOLING RESULTS IN THE OBESE
TO A MINIMUM OF MINUTES IN THE VERY THIN IN WHOM LONGER APPLICATIONS
INCREASE THE RISK OF TISSUE DAMAGE
#OLD PACKS SHOULD NOT BE APPLIED PRIOR TO EXERCISE
"
(EAT
$UE TO INSUFFICIENT EVIDENCE NO RECOMMENDATION CAN BE MADE
.ONE
0ULSED %LECTROMAGNETIC &IELDS 0%-&
0%-& APPLIED FOR MINUTES ON CONSECUTIVE DAYS IS BENEFICIAL IN THE
TREATMENT OF CALCIFIC TENDINITIS BOTH SHORT
AND MEDIUM
TERM 4HOUGH IT IS
ASSOCIATED WITH TREATMENT SORENESS THIS IS ONLY TRANSITORY
5LTRASOUND
)N CALCIFIC TENDINITIS HIGH INTENSITY 7CM CONTINUOUS ULTRASOUND APPLIED
DAILY FOR THREE WEEKS THEN ON ALTERNATE DAYS FOR THREE WEEKS GIVES SHORT
AND
MEDIUM
TERM BENEFIT
!
%XCEPT IN CALCIFIC TENDINITIS ULTRASOUND IS NOT RECOMMENDED FOR 3)3
,ASER AND 4RANSCUTANEOUS %LECTRICAL .ERVE 3TIMULATION 4%.3
$UE TO INSUFFICIENT EVIDENCE NO RECOMMENDATION CAN BE MADE
.ONE
$EEP TRANSVERSE FRICTION MASSAGE $4&-
$UE TO INSUFFICIENT EVIDENCE NO RECOMMENDATION CAN BE MADE
3TEROID INJECTION
.ONE
3TEROID INJECTIONS BENEFIT 3)3 IN THE SHORT TERM
)N VIEW OF THE ASSOCIATED RISKS IT IS SUGGESTED THAT STEROID INJECTIONS BE USED
ONLY AS NEEDED TO FACILITATE REHABILITATION )T IS ALSO SUGGESTED THAT NORMALLY
UNLESS SEVERE PAIN IS PRESENT A SEVERAL
WEEK TRIAL OF MORE CONSERVATIVE THERAPY
SHOULD PRECEDE THEIR USE
2ESISTIVE EXERCISE SHOULD BE WITHHELD FOR WEEKS FOLLOWING INJECTION
"
4HE SAME SUBACROMIAL SPACE SHOULD NOT BE INJECTED ON MORE THAN OCCASIONS
)MPROVEMENT OF POSTURE
2ECOMMENDATION
!N ATTEMPT TO CORRECT FORWARD
HEAD POSTURE IS APPROPRIATE IN VIEW OF ITS
ASSOCIATION WITH SHOULDER PAIN
"
2ESTORATION OF RANGE STRENGTH STABILITY AND SCAPULOHUMERAL RHYTHM
2ECOMMENDATION
s
0ASSIVE MOBILISATION OF THE UPPER QUADRANT AS NECESSARY AND APPLIED ACCORDING
TO STANDARD PRINCIPLES -AITLAND AUGMENTS THE BENEFICIAL EFFECTS OF
EXERCISE AND SHOULD BE UTILISED
! PROGRAMME OF EXERCISES TO RESTORE RANGE STRENGTH STABILITY AND SCAPULOHUMERAL
RHYTHM BENEFITS 3)3 ! SUGGESTED @CORE SET OF EXERCISES DERIVED FROM THE STRONGEST
AVAILABLE EVIDENCE IS DESCRIBED ILLUSTRATED AND GRADED BELOW 4HEY SHOULD
ALL BE PAINLESS
3CAPULOHUMERAL AND SCAPULOTHORACIC RHYTHMIC STABILISATION TRAINING MAY BE
INTRODUCED FROM AN EARLY STAGE UTILISING CLOSED KINETIC CHAIN WORK IN SITTING
STANDING IN FOUR
POINT KNEELING OR USING AN EXERCISE BALL SUCH THAT CONTROL IS
ACHIEVED IN PROGRESSIVELY LESS STABLE POSITIONS $URING THESE ACTIVITIES SCAPULAR
INSTABILITY SHOULD BE SCRUPULOUSLY AVOIDED FIGURES n
3TRENGTHENING EXERCISES MAY BE INTRODUCED IN THE FORM OF ISOTONIC MEDIAL AND
LATERAL ROTATION OF THE SHOULDER PERFORMED ELBOW
AT
SIDE -ORRISON ET AL
4HE PATIENT GENTLY GRIPS A TOWEL OR MAGAZINE BETWEEN ELBOW AND WAIST DURING
PERFORMANCE OF THE EXERCISE SO THAT CONTRACTION OF DELTOID IS DISCOURAGED
%LASTIC RESISTANCE BAND MAY BE USED TO PROVIDE LIGHT RESISTANCE AND THE PATIENT
BUILDS UP TO THREE SETS OF TEN REPETITIONS WITH TEN SECONDS REST AFTER EACH
REPETITION 7HEN THIS IS ACHIEVED THE RESISTANCE CAN BE INCREASED FIGURES n
"
s
3CAPULAR STABILITY WHEN PERFORMING STRENGTHENING EXERCISES IS PARAMOUNT
s
3TRETCHING EXERCISES MAY ALSO BE INTRODUCED AT AN EARLY STAGE 3TRENGTHENING
EXERCISES INCLUDE ANTERIOR AND POSTERIOR CAPSULAR STRETCH AS SHOWN IN
FIGURES n
"
s
s
s
2ECOMMENDATION
s
s
7HEN MUSCULAR STABILITY IS IMPROVING AND AS THE SHOULDER BECOMES MORE
COMFORTABLE PROGRESSION MAY BE MADE TO MORE VIGOROUS STRENGTHENING
EXERCISES 4HE SET OF EXERCISES SHOWN IN FIGURES n HAS BEEN SHOWN
ELECTROMYOGRAPHICALLY TO MOST EFFICIENTLY ACTIVATE THE SCAPULAR AND SHOULDER
MUSCULATURE &OR THOSE EXERCISES WHICH DO NOT UTILISE BODY WEIGHT ELASTIC
RESISTANCE BAND PROVIDES A CONVENIENT AND ADJUSTABLE RESISTANCE
'RADE
"
4HE EXERCISES ARE ALSO ILLUSTRATED IN !PPENDIX WHICH MAY BE COPIED FOR
DISTRIBUTION TO PATIENTS )T IS RECOMMENDED THAT THE EXERCISES ARE TAUGHT ON
A ONE
TO
ONE BASIS AND APPROPRIATE TEXT ADDED TO ENSURE THE PATIENTS FULL
UNDERSTANDING 4HE EXERCISES DESCRIBED REPRESENT A BASELINE AND SHOULD
NOT BE REGARDED AS AN EXHAUSTIVE LIST .UMEROUS OTHER EXERCISES WERE
IDENTIFIED IN THE LITERATURE AND ARE SUMMARISED IN !PPENDIX
2EFERENCES SUPPORTING 3ECTIONS n
!DEBAJO ! .ASH 0 AND (AZLEMAN "! 0ROSPECTIVE DOUBLE BLIND DUMMY PLACEBO CONTROLLED
STUDY COMPARING TRIAMCINOLONE HEXACETONIDE INJECTION WITH ORAL DICLOFENAC IN PATIENTS WITH ROTATOR
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(EINEMANN RD EDN
-AITLAND '$ 0ERIPHERAL -ANIPULATION /XFORD "UTTERWORTH (EINEMANN RD EDN
-ORRISON $3 &ROGAMENI !$ AND 7OODWORTH 0 .ON OPERATIVE TREATMENT OF SUBACROMIAL
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-OSELEY *" *R *OBE &7 0INK - 0ERRY * AND 4IBONE * %-' ANALYSIS OF THE SCAPULAR MUSCLES
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-URRELL '!# *ANG $ $ENG 8( AND (ANNAFIN *! %FFECTS OF EXERCISE ON ACHILLES TENDON HEALING
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0ARTINGTON 0& AND "ROOME '( $IAGNOSTIC INJECTION AROUND THE SHOULDER HIT AND MISS !
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3YSTEMATICALLY REVIEWED BY "UCHBINDER ET AL
2ODGERS *! AND #ROSBY ,! 2OTATOR CUFF DISORDERS !MERICAN &AMILY 0HYSICIAN n
3HANKWILER *! AND "URKHEAD *R 7: $IAGNOSIS EVALUATION AND CONSERVATIVE TREATMENT OF
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3PEED # AND (AZLEMAN " 3HOULDER PAIN ORAL NON STEROIDAL ANTI INFLAMMATORY DRUGS "-*
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VAN DER (EIJDEN '*-' VAN DER 7INDT $!7- AND DE 7INTER !& 0HYSIOTHERAPY FOR PATIENTS
WITH SOFT TISSUE SHOULDER DISORDERS A SYSTEMATIC REVIEW OF RANDOMISED CLINICAL TRIALS "-* n
7HITE 2 0AULL $ AND &LEMING + 2OTATOR CUFF TENDONITIS COMPARISON OF SUBACROMIAL INJECTION
OF LONG ACTING CORTICOSTEROID VERSUS INDOMETHACIN THERAPY *OURNAL OF 2HEUMATOLOGY n
7INTERS *# 3OBEL *3 'ROENIER +( !RENDZEN (* AND -EYBOOM DE JONG " #OMPARISON OF
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7INTERS *# DE *ONGH !# VAN DER 7INDT $!7- *ONQUIRE - DE 7INTER !& VAN DER (EIJDEN
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0RACTICE 'UIDELINE .(' 0RACTICE 'UIDELINE gSHOULDER COMPLAINTSg -AY !VAILABLE AT HTTPNHG
ARTSENNETNLGUIDELINES%HTM
7INTERS *# *ORRITSMA 7 'ROENIER +( 3OBEL *3 AND -EYBOOM
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9AMAKADO + 4HE TARGETING ACCURACY OF SUBACROMIAL INJECTION TO THE SHOULDER AN ARTHROGRAPHIC
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:UCKERMAN *$ -IRABELLO 3# .EWMAN $ 'ALLAGHER - AND #UOMO & 4HE PAINFUL SHOULDER
PART )) )NTRINSIC DISORDERS AND IMPINGEMENT SYNDROME !MERICAN &AMILY 0RACTITIONER n
7HEN TO REFER FOR AN ORTHOPAEDIC OPINION
*UDGING FROM LARGE RETROSPECTIVE STUDIES A HIGH PROPORTION OF PATIENTS WITH 3)3 CAN BE EXPECTED TO
RESPOND TO CONSERVATIVE MEASURES -ORRISON HAS REPORTED SATISFACTORY
EXCELLENT OUTCOMES IN
OF HIS SERIES OF SHOULDERS WITH 3)3 FOLLOWING A
WEEK REHABILITATION PROGRAMME AND
OF WHO SUBSEQUENTLY RELAPSED RESPONDED TO A RE
INSTITUTED PROGRAMME 0ARKER AND
3EITZ REPORT A POSITIVE RESPONSE TO A
MONTH REHABILITATION PROGRAMME IN THEIR REVIEW
OF CONSECUTIVE PATIENTS WITH @IMPINGEMENTINSTABILITY OVERLAP SYNDROME /NLY RELAPSED AND ALL
RESPONDED TO A RE
INSTITUTED PROGRAMME
#LEARLY THEN CONSERVATIVE MEASURES SHOULD BE GIVEN AN ADEQUATE OPPORTUNITY TO SUCCEED BEFORE
SURGERY IS CONTEMPLATED MOST AUTHORITIES RECOMMEND UP TO MONTHS 0ARKER AND 3EITZ
#AVALLO AND 3PEER &ONGEMIE ET AL !MERICAN !CADEMY OF /RTHOPAEDIC 3URGEONS
OR MONTHS IF REHABILITATION HAS BEEN CONTINUOUS !MERICAN !CADEMY OF /RTHOPAEDIC 3URGEONS
0RELIMINARY CONSERVATIVE CARE IS REDUNDANT IN MASSIVE FULL
THICKNESS CUFF TEARS HOWEVER 4HE PATIENT
PROBABLY MIDDLE
AGED OR ELDERLY IS UNABLE TO ACTIVELY ELEVATE AND MAY HAVE MARKEDLY WEAK ABDUCTION
AS WELL AS MUSCLE ATROPHY !MERICAN !CADEMY OF /RTHOPAEDIC 3URGEONS
2EFERENCES SUPPORTING 3ECTION
!MERICAN !CADEMY OF /RTHOPAEDIC 3URGEONS #RITERIA FOR SHOULDER SURGERY 2OSEMONT ),
!MERICAN !CADEMY OF /RTHOPAEDIC 3URGEONS !VAILABLE AT WWWGUIDELINEGOV
#AVALLO 2* AND 3PEER +0 3HOULDER INSTABILITY AND IMPINGEMENT IN THROWING ATHLETES -EDICINE
3CIENCE IN 3PORTS %XERCISE 3UPPLEMENT n
&ONGEMIE !% "USS $$ 2OLNICK 3* -ANAGEMENT OF SHOULDER IMPINGEMENT SYNDROME AND
ROTATOR CUFF TEARS !MERICAN &AMILY 0HYSICIAN !VAILABLE AT HTTPWWWAAFPORGAFPAP
FONGEMIEHTML
-ORRISON $3 &ROGAMENI !$ AND 7OODWORTH 0 .ON
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! n
0ARKER 2$ AND 3EITZ 7( 3HOULDER IMPINGEMENTINSTABILITY OVERLAP SYNDROME *OURNAL OF THE
3OUTHERN /RTHOPAEDIC !SSOCIATION n
!PPENDIX
'UIDELINE $EVELOPMENT 'ROUP '$'
*ANIS #UMMINS WHO LED THE '$' FROM THE OUTSET IS A SPECIALIST MUSCULOSKELETAL PHYSIOTHERAPIST WHO
HAS PRACTICED IN THE 53! AS WELL AS THE 5+ *ANIS HAS BEEN EMPLOYED BY 0ORTSMOUTH #ITY 4EACHING
0RIMARY #ARE 4RUST FOR THE LAST YEARS AND IS NOW SERVICE MANAGER OF THE PHYSIOTHERAPY OUT PATIENT
DEPARTMENT AT 3T -ARYS (OSPITAL AND FOR PHYSIOTHERAPY SERVICES IN THE 0ORTSMOUTH #ITY 4EACHING 0#4
3HE CONTINUES TO WORK AS A SPECIALIST IN THIS FIELD
#LAIRE *EFFRIES HAS AN EXTENSIVE BACKGROUND IN MUSCULOSKELETAL PHYSIOTHERAPY AND HAS BEEN EMPLOYED
BY 0ORTSMOUTH #ITY 4EACHING 0RIMARY #ARE 4RUST FOR YEARS ! SPECIALIST IN RHEUMATOLOGY AND
HYDROTHERAPY SHE IS BASED AT THE 1UEEN !LEXANDRA (OSPITAL 0ORTSMOUTH
.IGEL (ANCHARD IS A MUSCULOSKELETAL PHYSIOTHERAPIST AND TEACHER AT BOTH PRE
AND POST QUALIFYING LEVELS
AND FORMERLY LED THE -3C IN !LLIED (EALTH 0ROFESSIONAL 3TUDIES WITH ,ICENCE TO 0RACTISE 0HYSIOTHERAPY
AT THE 5NIVERSITY OF 4EESSIDE #URRENTLY A $EPARTMENT OF (EALTH RESEARCH FELLOW HE IS BASED AT THE
4EESSIDE #ENTRE FOR 2EHABILITATION 3CIENCES 5NIVERSITY OF 4EESSIDE WHERE HE IS WORKING IN THE AREA OF
SHOULDER DIAGNOSIS (E HAS RECEIVED A 2OBERT 7ILLIAMS AWARD FOR PREVIOUS RESEARCH IN THIS AREA
!PPENDIX
!DVISERS TO THE 'UIDELINE $EVELOPMENT 'ROUP
3UE "ARNARD
,ECTURER IN 0HYSIOTHERAPY $EPARTMENT OF (EALTH 3OCIAL #ARE
3OUTHAMPTON 5NIVERSITY AT THE TIME OF THE GUIDELINE DEVELOPMENT PROCESS
'AVIN (ARPER
#ONSULTANT /RTHOPAEDIC 3URGEON AND SHOULDER SPECIALIST
1UEEN !LEXANDRA (OSPITAL 0ORTSMOUTH
#HRISTINE (AYWARD
0ROFESSIONAL !DVISOR TO 0HYSIOTHERAPY 3ERVICES
0ORTSMOUTH 3OUTH %AST (AMPSHIRE (EALTH %CONOMY
*UDY -EAD
(EAD OF 2ESEARCH AND #LINICAL %FFECTIVENESS
4HE #HARTERED 3OCIETY OF 0HYSIOTHERAPY
#ERI 3EDGLEY
0ROFESSIONAL !DVISER 4HE #HARTERED 3OCIETY OF 0HYSIOTHERAPY
!PPENDIX
,OCAL PEER REVIEW
4HE FIRST DRAFT OF THE GUIDELINE DOCUMENT WAS SENT OUT FOR LOCAL PEER REVIEW 4HE REVIEWERS WERE
ASKED TO CONSIDER
s
4HE OVERALL DEVELOPMENT OF THE GUIDELINES
s
4HE VALIDITY OF THE RECOMMENDATIONS
s
4HE CLINICAL RELEVANCE OF THE GUIDELINES AND THE RECOMMENDATIONS
s
4HE FORMAT LAYOUT AND PRESENTATION OF THE GUIDELINE DOCUMENT
4HIS GROUP CONSISTED OF SUPERINTENDENTS AND TEAM LEADERS IN THE MUSCULOSKELETAL PHYSIOTHERAPY
SERVICES OF THE THREE 0RIMARY #ARE 4RUSTS 0#4S IN THE 0ORTSMOUTH AREA )N ADDITION THE DOCUMENT
WAS CIRCULATED TO MUSCULOSKELETAL OUT PATIENT TEAMS IN THE DISTRICT WHERE STUDENT JUNIOR AND SENIOR
PHYSIOTHERAPISTS WERE ASKED TO COMMENT ON THE POINTS ABOVE -EMBERS OF THE LOCAL PEER REVIEW GROUP
WERE
.IK #ARTER
3UPERINTENDENT 0HYSIOTHERAPIST
1UEEN !LEXANDRA (OSPITAL 0ORTSMOUTH #ITY 4EACHING 0#4
-ARTIN #OWDRY
3UPERINTENDENT 0HYSIOTHERAPIST
&AREHAM 'OSPORT 0#4
*ILL $ELANEY
&ORMER 3UPERINTENDENT 0HYSIOTHERAPIST
%AST (AMPSHIRE 0#4
'AVIN (ARPER
#ONSULTANT /RTHOPAEDIC 3URGEON AND SHOULDER SPECIALIST
1UEEN !LEXANDRA (OSPITAL 0ORTSMOUTH (OSPITALS .(3 4RUST
2ICHARD (ULL
#ONSULTANT 2HEUMATOLOGIST 1UEEN !LEXANDRA (OSPITAL
0ORTSMOUTH (OSPITALS .(3 4RUST
*OHN (UGHES
'ENERAL 0RACTITIONER (AVANT (EALTH #ENTRE %AST (AMPSHIRE 0#4
#HARLES ,EWIS
'ENERAL 0RACTITIONER &RATTON 2OAD 3URGERY AND #HAIRMAN
0ORTSMOUTH #ITY 0#4
$AVID 9OUNG
'ENERAL 0RACTITIONER &AREHAM 'OSPORT 0#4
!PPENDIX
.ATIONAL PEER REVIEW
4HE FIRST DRAFT OF THE GUIDELINE DOCUMENT WAS DISTRIBUTED TO SPECIAL INTEREST GROUPS LEADING ACADEMICS
AND CLINICIANS WITH A SPECIFIC INTEREST IN THIS AREA WHO HAD PREVIOUSLY AGREED TO CRITICALLY APPRAISE IT IN
RELATION TO THE FOLLOWING POINTS
s
4HE OVERALL DEVELOPMENT OF THE GUIDELINES
s
4HE VALIDITY OF THE RECOMMENDATIONS
s
4HE CLINICAL RELEVANCE OF THE GUIDELINES AND THE RECOMMENDATIONS
s
4HE FORMAT LAYOUT AND PRESENTATION OF THE GUIDELINE DOCUMENT
-EMBERS OF THE NATIONAL PEER REVIEW GROUP WERE
0AT $UNLEAVY
0RIVATE 0RACTITIONER AND PHYSIOTHERAPIST "RITISH OLYMPIC SWIMMING TEAM
0AULA &ITZPATRICK
3ENIOR 0HYSIOTHERAPIST #LINICAL 'OVERNANCE #O
ORDINATOR
.ORTH "RISTOL .(3 4RUST
*EREMY ,EWIS
3UPERINTENDENT 0HYSIOTHERAPIST #HELSEA 7ESTMINSTER (OSPITAL ,ONDON
#AROLINE -ETCALFE
2ESEARCH $EVELOPMENT 0HYSIOTHERAPIST )NSTITUTE OF 2EHABILITATION
2OYAL (ULL (OSPITAL
"ILL /RR
3UPERINTENDENT 0HYSIOTHERAPIST (ULL %AST 9ORKSHIRE (OSPITALS
.ORTH "RISTOL .(3 4RUST
4ONY 7ILSON
0RIVATE 0RACTITIONER #HICHESTER 7EST 3USSEX
!PPENDIX
2EVIEWERS COMMENTS AND '$' RESPONSES
!S A RESULT OF REVIEWERS FEEDBACK DURING LOCAL AND NATIONAL PEER REVIEW A NUMBER OF ALTERATIONS WERE
MADE TO THE GUIDELINES 4HE FOLLOWING ARE THE MAIN COMMENTS AND ACTIONS THAT WERE TAKEN
#OMMENT
)NCLUDE MORE DETAIL FOR THE GUIDELINE LITERATURE SEARCH STRATEGIES
!CTION TAKEN
4HE SPAN OF YEARS FOR WHICH THE LITERATURE WAS SEARCHED WAS CLARIFIED
KEY WORDS AND TERMS USED WERE CLARIFIED
%XAMPLES OF SEARCH STRATEGIES WERE INCLUDED IN THE APPENDICES
#OMMENT
$ISPLAY MORE CONCISE AND EASILY ACCESSIBLE DETAILS OF LITERATURE USED IN THE
TREATMENT SECTION OF THE GUIDELINES !PPENDIX
4ABLES FORMULATED DISPLAYING DETAILS OF THE LITERATURE USED WITHIN THE GUIDELINES
#OMMENT
.EED FOR CLEARER PRESENTATION OF INFORMATION IN THE TREATMENT CHAPTER OF
THE GUIDELINES
!CTION TAKEN
2EVISION OF INFORMATION INTO SECTIONS SPECIFIC TO TREATMENT RECOMMENDATIONS
IE COLD THERAPY HEAT THERAPY ETC
5SE OF EVIDENCE STATEMENTS TO HIGHLIGHT IMPORTANT POINTS FROM THE TEXT
'RADED RECOMMENDATION SECTIONS AT THE END OF THE DIAGNOSIS ASSESSMENT
AND TREATMENT SECTIONS
5SE OF BOLD AND TEXT FEATURES TO HIGHLIGHT THE EVIDENCE AND RECOMMENDATION
SUMMARIES
#OMMENT
#LEARER PRESENTATION REQUIRED FOR THE EXERCISE RECOMMENDATIONS SPECIFICALLY
IN THE STRENGTHENING SECTION OF THE TREATMENT CHAPTER
!CTION TAKEN
3EE !PPENDIX
%XERCISES PLACED IN TABULAR FORMAT AND IN SPECIFIC MUSCLE GROUPS
!NY INSTRUCTIONS ON PERFORMING THE EXERCISES STATED
!UTHORS OF THE RELEVANT ARTICLES STATED NEXT TO EACH EXERCISE
!CTION TAKEN
!PPENDIX
#ONSULTATION WITH SERVICE USERS 2ESULTS
4HE '$' HAS ENDEAVOURED TO OBTAIN PATIENTUSER INVOLVEMENT IN THIS PROJECT BY ASKING FOR FEEDBACK
ON THE EXERCISE SHEETS IN !PPENDIX 4HE EXERCISE DIAGRAMS WERE GIVEN TO A GROUP OF PATIENTS
ATTENDING A HYDROTHERAPY EXERCISE GROUP 4HE PATIENTS DID NOT SUFFER SPECIFICALLY WITH SHOULDER
IMPINGEMENT
4HE GROUP WERE TAUGHT THE EXERCISES BY A 3ENIOR )) PHYSIOTHERAPIST WHO WAS NOT PART OF THE '$' AND
THEN GIVEN THE DIAGRAMS AS AN AIDE MEMOIRE FOR PERFORMING THEM AT HOME 4HE PATIENTSUSERS WERE
ASKED TO PERFORM THE EXERCISES WITHIN THE LIMITS OF PAIN ONCE OR TWICE A DAY WITH A SUGGESTED NUMBER
OF REPETITIONS BEING SETS OF WITH A SECOND REST AFTER EACH SET SEE
4HE PATIENTSUSERS WERE ASKED TO CONSIDER THE FOLLOWING POINTS
s
7ERE THE DIAGRAMS CLEAR AND USEFUL AS AN AID TO MEMORY FOLLOWING THE VERBAL EXPLANATION GIVEN TO
YOU BY THE PHYSIOTHERAPIST
s
7ERE THE RECOMMENDED NUMBERS OF REPETITIONS REALISTIC
&EEDBACK
PATIENTSUSERS GAVE WRITTEN FEEDBACK TWO WEEKS LATER AND THE FOLLOWING COMMENTS
WERE MADE
s
PATIENTS FELT THE DIAGRAMS NEEDED ARROWS TO INDICATE THE DIRECTION OF MOVEMENT OR A SECOND
PICTURE TO INDICATE MORE CLEARLY HOW IT SHOULD BE PERFORMED
s
PATIENTS WERE HAPPY WITH THE EXERCISES DEPICTED
s
!LL PATIENTS USERS FELT THE EXERCISE REPETITIONS WERE REALISTIC AND ACHIEVABLE
4HE PHYSIOTHERAPIST WHO TAUGHT THE GROUP GAVE THE FOLLOWING FEEDBACK
s
)NITIALLY THE PATIENTS MISINTERPRETED SOME OF THE EXERCISES ON THE SHEET PRIOR TO THE VERBAL
EXPLANATION
s
)T HAD BEEN DIFFICULT TO EXPLAIN ALL THE NEW EXERCISES IN A GROUP SITUATION AS INDIVIDUAL QUERIES MAY
NOT HAVE BEEN DEALT WITH ADEQUATELY
4HE '$' HAVE CONSIDERED THIS FEEDBACK AND RECOMMEND THAT IF A PHYSIOTHERAPIST CHOOSES TO
USE THE DIAGRAMS
! FULL EXPLANATION OF THE EXERCISES SHOULD BE GIVEN PREFERABLY ON A ONE
TO
ONE BASIS
!RROWS INDICATING DIRECTION OF MOVEMENT OR WRITTEN INSTRUCTIONS SHOULD BE ADDED TO THE DIAGRAMS
AS NECESSARY TO ENABLE THE PATIENTUSER TO PERFORM THE EXERCISES SATISFACTORILY
!PPENDIX
$ETAILED ELECTRONIC SEARCH STRATEGY
3EARCH 3TRATEGIES
3UBJECT 3EARCH FOR !-%$ !LLIED AND #OMPLEMETARY -EDICINE
3HOULDER )MPINGEMENT 3YNDROME
3HOULDER IMPINGEMENT SYNDROMEMP
3UBACROMIAL IMPINGEMENT SYNDROMEMP
SHOULDER OR SUBACROMIAL AND IMPINGEMENT AND SYNDROME MP
;MP ABSTRACT HEADING WORDS TITLE=
OR OR OR
LIMIT TO %NGLISH LANGUAGE
FROM KEEP
3UBJECT 3EARCH FOR 0RE -%$,).% -%$,).% )NDEX -EDICUS
3HOULDER )MPINGEMENT 3YNDROME
3HOULDER IMPINGEMENT SYNDROME MP
3UBACROMIAL IMPINGEMENT SYNDROMEMP
SHOULDER OR SUBACROMIAL AND IMPINGEMENT AND SYNDROME MP ;MP TI AB RW SH=
OR OR OR
LIMIT TO HUMAN AND %NGLISH LANGUAGE ;,IMIT NOT VALID IN 0RE -%$,).% RECORDS WERE RETAINED=
FROM KEEP
3UBJECT 3EARCH FOR #).!(, #UMMULATIVE )NDEX TO .URSING AND !LLIED (EALTH
3HOULDER IMPINGEMENT SYNDROME
3HOULDER IMPINGEMENT SYNDROMEMP
3UBACROMIAL IMPINGEMENT SYNDROMEMP
SHOULDER OR SUBACROMIAL AND IMPINGEMENT AND SYNDROME MP ;MP TITLE CINAHL SUBJECT
HEADING ABSTRACT INSTRUMENTATION=
OR OR OR
LIMIT TO %NGLISH LANGUAGE
!PPENDIX
!RTICLE APPRAISAL SYSTEM
#RITICAL APPRAISAL SKILLS
QUESTIONS TO HELP YOU MAKE SENSE OF A RESEARCH ARTICLES ABOUT CLINICAL EFFECTIVENESS
'ENERAL #OMMENTS
s
4HREE BROAD ISSUES NEED TO BE CONSIDERED WHEN APPRAISING A RESEARCH ARTICLE ABOUT CLINICAL
EFFECTIVENESS
! !RE THE RESULTS OF THE ARTICLE VALID
" 7HAT ARE THE RESULTS
# 7ILL THE RESULTS HELP ME
4HE FOLLOWING QUESTIONS ARE DESIGNED TO HELP YOU THINK ABOUT THE ISSUES SYSTEMATICALLY
s
4HE FIRST TWO QUESTIONS ARE SCREENING QUESTIONS AND CAN BE ANSWERED QUICKLY )F THE ANSWER TO BOTH
IS YES IT IS WORTH PROCEEDING WITH THE REMAINING QUESTIONS
s
4HERE IS A FAIR DEGREE OF OVERLAP BETWEEN SEVERAL OF THE QUESTIONS
s
9OU ARE ASKED TO RECORD YES NO OR CANT TELL TO MOST OF THE QUESTIONS
s
! NUMBER OF ITALICISED PROMPTS ARE GIVEN AFTER EACH QUESTION 4HESE ARE DESIGNED TO REMIND YOU
WHY THE QUESTION IS IMPORTANT
s
4HE QUESTIONS ARE ADAPTED FROM 'UYATT '( 3ACKETT ET AL 5SERS'UIDE TO 4HE -EDICAL
,ITERATURE )) (OW TO USE AN ARTICLE ABOUT THERAPY OR PREVENTION *!-!
AND *!-!
! !RE THE RESULTS OF THE ARTICLE VALID
3CREENING 1UESTIONS
$ID THE ARTICLE ADDRESS A CLEARLY FOCUSED ISSUE
s
s
s
(INT !N ISSUE CAN BE FOCUSED IN TERMS OF
THE POPULATION STUDIED
THE INTERVENTION GIVEN
THE OUTCOMES CONSIDERED
7AS THE STUDY DESIGNED IN A WAY WHICH ALLOWED
IT TO ADDRESS THE ISSUE
s
s
s
(INT ! WELL DESIGNED STUDY SHOULD
INCLUDE A CONTROL GROUP
RECRUIT CONTROL AND INTERVENTION GROUPS FROM THE SAME POPULATION
ALLOCATE SUBJECTS TO GROUPS RANDOMLY
$ETAILED 1UESTIONS
7AS PATIENT SELECTION CARRIED OUT APPROPRIATELY
s
s
s
(INT #HECK TO SEE WHETHER
THE SOURCE OF PATIENTS WAS REPORTED
REPRESENTATIVE PATIENTS WERE RECRUITED CONCURRENTLY TO BOTH GROUPS
INCLUSION AND EXCLUSION CRITERIA WERE DEFINED
7AS THE STUDY DESIGNED APPROPRIATELY
s
s
s
(INT #HECK TO SEE WHETHER
ALLOCATION WAS TRULY RANDOM CONCEALED
THE NEW TREATMENT WAS COMPARED WITH AN APPROPRIATE CONTROL TREATMENT
RESEARCHERS AND SUBJECTS WERE BLINDED TO THE TREATMENT ALLOCATION
7AS THE STUDY CONDUCTED AND ANALYSED APPROPRIATELY
s
s
s
s
s
(INT #HECK TO SEE WHETHER
THE RATE OF REFUSAL WAS STATED AND WAS ACCEPTABLY LOW
A HIGH PROPORTION OF PATIENTS COMPLETED THEIR TREATMENT REGIMES
ALL PATIENTS WERE PROPERLY ACCOUNTED FOR
DATA WERE ANALYSED ON THE BASIS OF THE INTENTION TO TREAT
ANALYSES TOOK ACCOUNT OF THE BASELINE DIFFERENCES IN PROGNOSTIC FACTORS
BETWEEN GROUPS
9ES
#ANT TELL
.O
9ES
#ANT TELL
.O
9ES
#ANT TELL
.O
9ES
#ANT TELL
.O
9ES
#ANT TELL
.O
" 7HAT ARE THE RESULTS
7HAT ARE THE RESULTS OF THE STUDY
s
s
s
(INT #ONSIDER
THE SIZE OF THE TREATMENT EFFECT
THE UNITS THAT THE RESULTS ARE EXPRESSED IN
WHETHER THE SIZE OF TREATMENT EFFECT IS LIKELY TO BE CLINICALLY IMPORTANT
(OW PRECISE ARE THE RESULTS
s
s
(INT #ONSIDER
THE LARGEST AND SMALLEST TREATMENT EFFECTS WHICH ARE CONSISTENT WITH THE
OBSERVED RESULT
WHETHER THE PRECISION WAS GOOD ENOUGH TO EXCLUDE A CHANCE EXPLANATION
FOR THE RESULT
(AVE ALTERNATIVE EXPLANATIONS FOR THE RESULTS BEEN EXPLORED AND DISCOUNTED
$O YOU THINK THAT THE PATIENTS RECRUITED TO THE STUDY WERE SIMILAR ENOUGH
TO YOUR POPULATION
7ERE ALL CLINICALLY IMPORTANT OUTCOMES CONSIDERED
(INT #ONSIDER THE IMPORTANCE OF
OBJECTIVE CLINICAL MEASURES
SUBJECTIVE PATIENT
ORIENTATED MEASURES EG QUALITY OF LIFE
SIDE EFFECTS
!RE THE BENEFITS WORTH THE HARMS AND COSTS
9ES
#ANT TELL
.O
7ILL THE RESULTS HELP ME
#AN THE RESULTS BE APPLIED TO MY PATIENTS
s
s
s
9ES
#ANT TELL
.O
4HIS IS UNLIKELY TO BE ADDRESSED BY THE ARTICLE "UT WHAT DO YOU THINK
9ES
#ANT TELL
.O
9ES
#ANT TELL
.O
9ES
#ANT TELL
.O
!PPENDIX
4ABLE OF SYSTEMATIC REVIEWS AND CRITICAL APPRAISAL OF THE
PRIMARY LITERATURE
3TUDY
4YPE
3ETTING
3AMPLE
!LBRIGHT * ET AL
3YSTEMATIC REVIEW
#LINICAL
2#4S ON THE EFFICACY
OF PHYSIOTHERAPY
INTERVENTIONS FOR SHOULDER
PAIN
"ANG AND $EYLE
2#4
#LINICAL
PATIENTS MALE
WITH 3)3
)NTERVENTION
'ROUP RECEIVED
SUPERVISED EXERCISES
FOR MOBILISING
-EAN AGE OF THE
STRENGTHENING OVER
TREATMENT GROUP GROUP SESSIONS
WAS 3$ RANGE
'ROUP RECEIVED PASSIVE
OF THE CONTROL
GROUP GROUP WAS MOBILISATIONS IN ADDITION
n
$URATION OF SYMPTOMS
WAS COMPARABLE
YEARS 3$ IN GROUP
IN GROUP
"ECKER ( ET AL
$ESCRIPTIVE RETROSPECTIVE #LINICAL
REVIEW
UNSELECTED PATIENTS
WITH FINGER FLEXOR TENDON
LACERATIONS WERE
FOLLOWED UP FOR AN
AVERAGE OF MONTHS
"ROSSEAU , ET AL
3YSTEMATIC REVIEW
#LINICAL
2#4S ON THE EFFICACY OF
$4& FOR TENDINITIS
3URGICAL REPAIR WITH
GENTLE ACTIVE MOVEMENTS
FROM THE FIRST POST
OPERATIVE DAY
/UTCOME
MEASURES
2ESULTS
)SOMETRIC STRENGTH
USING AN ELECTRONIC
DYNAMOMETER
3TRENGTH IMPROVED
SIGNIFICANTLY IN GROUP
BUT NOT GROUP
0AIN ON ACTIVE
ABDUCTION ISOMETRIC
@BREAK TESTING FUNCTIONAL
ACTIVITIES
"OTH GROUPS PAIN
FUNCTION IMPROVED
SIGNIFICANTLY BUT GROUP
S SIGNIFICANTLY MORE SO
! FUNCTIONAL
QUESTIONNAIRE
#RITICAL APPRAISAL CHECKLIST FOR CLINICAL )NCLUDED IN
EFFECTIVENESS STUDIES WHERE APPLICABLE A SYSTEMATIC
REVIEW
3EE FOOT OF TABLE P FOR KEY
9
9
9
.
.
9
9
9
9
.
'REEN
!SSESSORS WERE @BLIND AS
TO PATIENT GROUPS
2ANGE OF MOTION
)NCIDENCE OF TENDON
RUPTURE
4HE PATTERN OF RECOVERY 9
;DIFFERED= FROM THAT SEEN
IN PATIENTS TREATED BY
CONVENTIONAL METHODS x
MOST PATIENTS HAD GOOD
RANGE OF MOTION AT
WEEK AND WERE ABLE TO
TOUCH THEIR PALMS AT TO
WEEKS
4HE INCIDENCE OF
RUPTURE WAS 4HE
AUTHOR ATTRIBUTED THIS
TO NON
SELECTION OF THE
PATIENTS SOME OF WHOM
WOULD NOT COMPLY WITH
INSTRUCTIONS TO MOBILISE
GENTLY
3TUDY
4YPE
3ETTING
3AMPLE
)NTERVENTION
"HMER !3 ET AL
$ESCRIPTIVE
#LINICAL
3EE "ROX
3EE "ROX
"ROX *) ET AL
2#4
#LINICAL
3EE "ROX
3EE "ROX
"ROX *) ET AL
2#4
#LINICAL
PATIENTS WITH 3)3
MONTHS STAGE ))
RESISTANT TO .3!)$S
PHYSIOTHERAPY
'ROUP UNDERTOOK
LOW
RESISTANCE HIGH
REPETITION EXERCISES FOR
HOUR DAILY INITIALLY
IN SLING SUSPENSION
%MPHASIS WAS PLACED
ON ESTABLISHING NORMAL
MOVEMENT PATTERNS
5NRESTRICTED ACTIVITY WAS
TYPICALLY ALLOWED AFTER
n WEEKS BUT THE
PROGRAMME CONTINUED
FOR n MONTHS
! PHYSIOTHERAPIST
SUPERVISED THE EXERCISES
TWICE A WEEK IN THE EARLY
STAGES BUT THIS WAS
GRADUALLY REDUCED
'ROUP UNDERWENT
ARTHROSCOPIC SURGERY
'ROUP RECEIVED PLACEBO
DETUNED LASER TWICE
WEEKLY FOR WEEKS
"UCHBINDER 2 ET AL
3YSTEMATIC REVIEW
#LINICAL
2#4S ON THE EFFICACY
OF CORTICOSTEROID
INJECTIONS FOR SHOULDER
PAIN
#ONROY $% AND (AYES
2#4
#LINICAL
PATIENTS MALE WITH 4REATMENTS WERE GIVEN
3)3
TIMES WEEKLY FOR
WEEKS
-EAN AGE OF THE
TREATMENT GROUP GROUP "OTH GROUPS RECEIVED HOT
WAS YEARS 3$
PACKS AND EXERCISES TO
THE CONTROL GROUP MOBILISE AND STRENGTHEN
GROUP
PHYSIOLOGICAL STRETCHES
SOFT TISSUE MOBILISATION
/THER VARIABLES WERE
AND ADVICE
COMPARABLE ACROSS THE
GROUP
'ROUP RECEIVED
ACCESSORY SHOULDER JOINT
MOBILISATIONS ACCORDING
TO STANDARD -AITLAND
PRINCIPLES IN ADDITION
/UTCOME
MEASURES
2ESULTS
#RITICAL APPRAISAL CHECKLIST FOR CLINICAL )NCLUDED IN
EFFECTIVENESS STUDIES WHERE APPLICABLE A SYSTEMATIC
REVIEW
3EE FOOT OF TABLE P FOR KEY
3EE "ROX
3EE "ROX
3EE "ROX
3EE "ROX
3EE "ROX
3EE "ROX
3EE "ROX
'REEN
VAN DER (EIJDEN
.EER SHOULDER SCORE
WHICH INCLUDES MEASURES
OF PAIN OVER THE PREVIOUS
WEEK CLINICAL TESTS OF
STRENGTH REACHING
STABILITY ACTIVE RANGE OF
MOTION AND RADIOLOGICAL
EVALUATION 0OSSIBLE
SCORES RANGE FROM n
4HE CRITERION FOR SUCCESS
WAS A SCORE
%VALUATION AT
MONTHS AND FOLLOW UP AT
YEARS
4HE SUCCESS RATE WAS
HIGHER FOR GROUPS
AND THAN GROUP
AT MONTHS P
AND YEARS P
9
9
9
.
9
9
9
9
.
'REEN
'ROUP HAD A SIGNIFICANT 9
REDUCTION IN HOUR
PAIN INTENSITY P
AND PAIN ON IMPINGEMENT
0AIN ON IMPINGEMENT TESTING P V GROUP
TESTING 6!3
9
9
.
.
9
.
9
.
'REEN
'ROUPS DID NOT
SIGNIFICANTLY DIFFER FROM
ONE ANOTHER IN TERMS OF
OUTCOME
-AXIMUM PAIN
INTENSITY IN PRECEDING
HOURS 6!3
!CTIVE RANGE OF
MOTION
"OTH GROUPS MOTION AND
FUNCTION IMPROVED
!BILITY TO PERFORM
A STANDARDISED SET OF
FUNCTIONAL ACTIVITIES
!SSESSORS WERE @BLIND AS
TO PATIENT GROUPS
3TUDY
4YPE
3ETTING
3AMPLE
)NTERVENTION
$AVIDSON #* ET AL
#ONTROLLED TRIAL
,ABORATORY
MALE 3PRAGUE $AWLEY !NIMALS WERE ASSIGNED TO
RATS
GROUPS
'ROUP UNDERWENT NO
INTERVENTION
'ROUPS HAD ACHILLES
TENDINOSIS INDUCED BY
COLLAGENASE INJECTION
'ROUPS RECEIVED
DEEP LONGITUDINAL
MASSAGE BY MEANS OF AN
ALUMINIUM INSTRUMENT TO
THE LESION FOR MINUTES
ON EACH OF DAYS
$E "RUIJN 2
$ESCRIPTIVE
%NWEMEKA #3 ET AL %XPERIMENTAL
#LINICAL
PATIENTS WITH VARIOUS
SOFT TISSUE LESIONS
$EEP TRANSVERSE FRICTION
,ABORATORY
7ISTAR RATS
!LL ANIMALS UNDERWENT
UNILATERAL ACHILLES TENDON
TRANSECTION SUTURING
IMMOBILISATION IN PLASTER
CAST
)N GROUP THE SPLINTS
WERE REMOVED AFTER
DAYS IN GROUP THE
SPLINTS WERE REMOVED
FROM DAYS n THEN
REPLACED IN GROUP THE
CONTROLS SPLINTS REMAINED
IN SITU
/UTCOME
MEASURES
2ESULTS
#RITICAL APPRAISAL CHECKLIST FOR CLINICAL )NCLUDED IN
EFFECTIVENESS STUDIES WHERE APPLICABLE A SYSTEMATIC
REVIEW
3EE FOOT OF TABLE P FOR KEY
!LL ANIMALS UNDERWENT
RUNNING GAIT ANALYSIS
STRIDE LENGTH
FREQUENCY HIP KNEE
ANKLE ANGULAR
DISPLACEMENT ON A
FIXED
SPEED TREADMILL
4HIS WAS CONDUCTED PRE
INJECTION AND ON THE DAYS
PRECEDING MASSAGE DAYS
.
/NLY GROUP SIGNIFICANTLY .OT A CLINICAL EFFECTIVENESS STUDY
IMPROVED ITS RUNNING
PERFORMANCE AFTER INJURY
REGAINING ORIGINAL GAIT
PATTERNS BY THE END OF
THE STUDY
&IBROBLASTIC PROLIFERATION
WAS SEEN IN GROUPS
WITH THE LARGEST
SIGNIFICANT INCREMENT
4HE ANIMALS WERE
IN THE LATTER P V
SACRIFICED DAYS
GROUPS ON POST
AFTER THE LAST MASSAGE
HOC TESTING &IBROBLASTIC
TREATMENT THE TENDONS ACTIVATION WAS OBSERVED
EXCISED FOR MICROSCOPY IN GROUPS
)NCREMENTS IN FIBRONECTIN
WERE ALSO OBSERVED
IN GROUPS
SUGGESTING THAT MASSAGE
PER SE STIMULATES
FIBROBLASTIC ACTIVATION AND
FIBRONECTIN SYNTHESIS
'ROUP DID NOT
DEMONSTRATE BENEFITS IN
COLLAGEN DISPOSITION OVER
GROUP
9 .
0ATIENT REPORTED ANALGESIC /NSET OF ANALGESIA IN
EFFECT
n MIN MEAN
$URATION MINn HRS
MEAN HOURS
.OT A CLINICAL EFFECTIVENESS STUDY
!NIMALS WERE SACRIFICED 4HE HIGHEST MEAN
AT DAYS TENDON
BREAKING STRENGTH WAS
BREAKING STRENGTHS
RECORDED FOR GROUP
EVALUATED
P V EACH OF
GROUPS
4ENDON
END SEPARATIONS
RE
RUPTURES WERE
OBSERVED IN GROUPS
BUT NOT IN GROUP
3TUDY
4YPE
3ETTING
3AMPLE
%USTACE *! ET AL
$ESCRIPTIVE
#LINICAL
PATIENTS WITH SHOULDER )NTRA ARTICULAR INJECTION
SYMPTOMS OF AT LEAST
OF TRIAMCINILONE
MONTHS DURATION
RADIOGRAPHIC CONTRAST
MATERIAL USING
STANDARDISED TECHNIQUE
'INN +! ET AL
2#4
#LINICAL
PATIENTS MALE
WITH UNILATERAL SHOULDER
PAIN 0AIN ATTRIBUTABLE
TO 3)3 IN -EDIAN
AGE OF TREATMENT GROUP
GROUP
CONTROL GROUP GROUP
!LL OTHER
VARIABLES CLOSELY MATCHED
'REEN 3 ET AL
3YSTEMATIC REVIEW
#LINICAL
TRIALS ON THE EFFICACY
OF PHYSIOTHERAPY
INTERVENTIONS FOR SHOULDER
PAIN
'REENFIELD " ET AL
$ESCRIPTIVE
#LINICAL
HEALTHY SUBJECTS
PATIENTS WITH SHOULDER
@OVERUSE INJURIES
)NTERVENTION
'ROUP RECEIVED NO
TREATMENT
)N GROUP SPECIFIC
TREATMENT WAS AT
PHYSIOTHERAPISTS
DISCRETION BUT WAS
DIRECTED AT STRETCHING
AND OR STRENGTHENING
MUSCLES AS DEEMED
APPROPRIATE RETRAINING
SCAPULOHUMERAL RHYTHM
/UTCOME
MEASURES
2ADIOGRAPHS WERE
TAKEN IMMEDIATELY
POST
INJECTION
SYMPTOMS 6!3 RANGE
OF MOVEMENT WERE
EVALUATED PRE
INJECTION
WEEKS POST
INJECTION
2ESULTS
#RITICAL APPRAISAL CHECKLIST FOR CLINICAL )NCLUDED IN
EFFECTIVENESS STUDIES WHERE APPLICABLE A SYSTEMATIC
REVIEW
3EE FOOT OF TABLE P FOR KEY
OF ATTEMPTED 9
SUBACROMIAL INJECTIONS
WERE JUDGED TO BE
ACCURATELY PLACED
OF
ATTEMPTED GLENOHUMERAL
INJECTIONS
.
9
9
.
.
9
9
9
'REEN
6AN DER (EIJDEN
4HERE WERE SIGNIFICANT
DIFFERENCES IN RELATION
TO OUTCOME BETWEEN
THE ACCURATELY PLACED
INACCURATELY PLACED
GROUPS
2ANGE OF MOTION
)SOMETRIC STRENGTH
6!3 FOLLOWING
STANDARDISED REACHING
TASK
9
'ROUP IMPROVED
SIGNIFICANTLY V GROUP
IN TERMS OF RANGE OF
ABDUCTION P AND
FLEXION P AND
SELF RATED DISABILITY SCORE
P
3ELF RATED DISABILITY
SCORE
!SSESSORS WERE BLIND AS
TO PATIENT GROUPS
3CAPULAR PROTRACTION
ROTATION FORWARD HEAD
POSITION MID
THORACIC
CURVATURE PASSIVE
SCAPTION WERE EVALUATED
USING STANDARDISED
VALIDATED TECHNIQUES
&ORWARD HEAD POSTURE
WAS SIGNIFICANTLY GREATER
IN THE PATIENT GROUP
P
.OT A CLINICAL EFFECTIVENESS STUDY
3TUDY
4YPE
(ART $0 AND $AHNERS ,% %XPERIMENTAL
(OLLINGWORTH '2 ET AL
2#4
3ETTING
3AMPLE
)NTERVENTION
,ABORATORY
4HE MEDIAL COLLATERAL
LIGAMENT OF THE KNEE WAS
TRANSACTED IN MALE
3PRAGUE
$AWLEY RATS
)N ANIMALS GROUP
SECONDARY STABILISING
LIGAMENTS WERE LEFT
INTACT )N ANIMALS
GROUP THE SECONDARY
STABILISING LIGAMENTS WERE
TRANSACTED IN ADDITION TO
THE COLLATERAL LIGAMENT
%ACH GROUP WAS
DIVIDED INTO @SURGICAL
REPAIR OR @NO REPAIR
SUBGROUPS AND THESE
WERE FURTHER DIVIDED INTO
@IMMOBILISATION OR @FREE
MOBILISATION SUBGROUPS
#LINICAL
PATIENTS WITH MIXED
DIAGNOSIS SHOULDER PAIN
)NJECTION OF ML
METHYLPREDNISOLONE
ACETATE MGML MIXED
WITH LIDOCAINE INTO
'ROUP TENDER POINT
'ROUP ANATOMICAL
STRUCTURE DETERMINED BY
#YRIAXS SELECTIVE TISSUE
TENSION EXAMINATION
#ROSS
OVER INJECTION GIVEN
IF PAIN NOT CONSIDERABLY
REDUCED AFTER WEEK
)TZKOVITCH $ ET AL
2#4
#LINICAL
OUTPATIENTS WITH
MEAN AGE YEARS 3$
YEARS RANGE
WITH 3)3 MOVEMENT
RESTRICTION PAIN
AT REST OR ON ACTIVE
MOVEMENT
WEEKLY PERIARTICULAR
INJECTION OF TENOXICAM
MG OR PLACEBO FOR
n WEEKS
/UTCOME
MEASURES
2ESULTS
#RITICAL APPRAISAL CHECKLIST FOR CLINICAL )NCLUDED IN
EFFECTIVENESS STUDIES WHERE APPLICABLE A SYSTEMATIC
REVIEW
3EE FOOT OF TABLE P FOR KEY
4HE ANIMALS WERE
SACRIFICED AT DAYS AND
THE LIGAMENTS EVALUATED
FOR LAXITY AND STRENGTH
)F THE SECONDARY
.OT A CLINICAL EFFECTIVENESS STUDY
STABILISERS WERE INTACT
THE LIGAMENTS WERE
LESS LAX IN THE @FREE
MOBILISATION THAN IN
THE @IMMOBILISATION
SUBGROUPS )F THE
SECONDARY STABILISERS WERE
NOT INTACT THIS SITUATION
REVERSED
!LL LIGAMENTS WERE
WEAKER THAN CONTROLS BUT
THE @FREE MOBILISATION
SUBGROUPS WERE ALL
SIGNIFICANTLY STRONGER THAN
THEIR @IMMOBILISATION
COUNTERPARTS P
9
9
9
9
9
9
9
9
.
9
#LINICAL INDEX PAIN DURING !LL OUTCOME MEASURES
ACTIVE MOVEMENT AND AT IMPROVED SIGNIFICANTLY
REST 6!3 ACTIVE RANGE OF MORE IN THE TENOXICAM
MOTION PAIN ON PRESSURE TREATED GROUP V THE
PATIENTS AND CLINICIANS
CONTROLS
GLOBAL IMPRESSION
4HERE WERE NO SIGNIFICANT
DIFFERENCES IN SAFETY
ASSESSMENTS BETWEEN
GROUPS
9
9
9
9
9
.
3UCCESS DEFINED AS
REDUCTION OF PAIN FROM
SEVERE TO MILD OR NIL
WITH CORRESPONDING
CLEARING OF SIGNS ON
OBJECTIVE EXAMINATION
3IGNIFICANT BENEFIT IN
ANATOMICAL INJECTION
GROUP OVER TENDER POINT
INJECTION V
SUCCESS P
"UCHBINDER
3TUDY
4YPE
3ETTING
-ORRISON $3 ET AL
$ESCRIPTIVE RETROSPECTIVE #LINICAL
REVIEW
3AMPLE
)NTERVENTION
SHOULDERS IN
PATIENTS MALE
DIAGNOSED WITH 3)3
-EAN AGE YEARS
n
WEEK COURSE OF .3!)$S
7HEN PAIN ALLOWED SOFT
TISSUE STRETCHING UNTIL FULL
RANGE RESTORED 4HEN A
WEEK PROGRAMME OF
STRENGTHENING EXERCISES
EMPHASISING SHOULDER
MEDIAL AND LATERAL
ROTATION
7HEN THE SHOULDER
WAS PAINLESS AND
FULLY FUNCTIONAL A
GENERAL STRENGTHENING
PROGRAMME WAS
INSTITUTED IN PATIENTS WITH
HIGH FUNCTIONAL DEMANDS
-OSELEY *" JR ET AL
$ESCRIPTIVE
#LINICAL ,ABORATORY
NORMAL MALE
VOLUNTEERS
SCAPULAR MUSCLE
STRENGTHENING EXERCISES
WERE EVALUATED
-URRELL '!# ET AL
%XPERIMENTAL
,ABORATORY
MALE 3PRAGUE
$AWLEY
RATS RANDOMISED TO EACH
OF AN EXPERIMENTAL GROUP
GROUP AND A CONTROL
GROUP GROUP
)N BOTH GROUPS THE
!CHILLES TENDON WAS
SURGICALLY TRANSECTED
'ROUP UNDERWENT
MINUTES SWIMMING
EACH DAY
/UTCOME
MEASURES
#LINICIAN
ADMINISTERED
3HOULDER
2ATING 3CALE
OF THE 5NIVERSITY OF
#ALIFORNIA AT ,OS !NGELES
COVERING THE DOMAINS OF
PAIN FUNCTION RANGE OF
MOVEMENT STRENGTH AND
PATIENT SATISFACTION
2ESULTS
/F THE TOTAL HAD
A SATISFACTORY GOOD OR
EXCELLENT RESULT
DERIVED NO BENEFIT AND
PROCEEDED TO SURGERY
DERIVED NO BENEFIT
BUT DECLINED SURGERY
#RITICAL APPRAISAL CHECKLIST FOR CLINICAL )NCLUDED IN
EFFECTIVENESS STUDIES WHERE APPLICABLE A SYSTEMATIC
REVIEW
3EE FOOT OF TABLE P FOR KEY
9
.
9
.
9
/F THOSE WITH A
SATISFACTORY GOOD OR
EXCELLENT RESULT
RELAPSED AGAIN
RESPONDED TO THE
INTERVENTION DID
NOT
$YNAMIC FINE
WIRE INTRAMUSCULAR
ELECTROMYOGRAPHY
&UNCTIONAL PERFORMANCE
WAS DETERMINED BY
MEASURING HINDPAW
PRINTS OF WALKING RATS
PRE
OPERATIVELY ON
ALTERNATE POST
OPERATIVE
DAYS
!GE YEARS ACROMIAL
TYPE ) AS AGAINST TYPES ))
OR ))) AND ACUTENESS
V @NON
ACUTENESS OR
CHRONICITY WERE ALL
ASSOCIATED WITH MORE
SUCCESSFUL OUTCOMES
! CORE SET OF EXERCISES
.OT A CLINICAL EFFECTIVENESS STUDY
NAMELY
SCAPTION
ROWING
@PUSH UP PLUS
IE PLUS PROTRACTION
@PRESS UP IN SITTING
POSITION LIFTING BOTTOM
FROM CHAIR
WAS FOUND TO EFFICIENTLY
ACTIVATE ALL MUSCLES
3UPPLEMENTAL EXERCISE
.OT A CLINICAL EFFECTIVENESS STUDY
HAD NO EFFECT ON
FUNCTIONAL OR MECHANICAL
RECOVERY
2ATS WERE SACRIFICED ON
DAY THE TENDONS
EVALUATED MORPHOLOGICALLY
MECHANICALLY
3TUDY
4YPE
3ETTING
0ARKER 2$ ET AL
$ESCRIPTIVE RETROSPECTIVE #LINICAL
REVIEW
3AMPLE
)NTERVENTION
CONSECUTIVE
PATIENTS MALE WITH
IMPINGEMENT INSTABILITY
OVERLAP SYNDROME
-EAN AGE WAS YEARS
RANGE n YEARS
2EST .3!)$S AND HEAT
FOR n DAYS OR UNTIL
SIGNIFICANT PAIN ABATED
!LL HAD A POSITIVE
IMPINGEMENT SIGN A
POSITIVE APPREHENSION
TEST WHICH REMAINED SO
AFTER THE IMPINGEMENT
INJECTION TEST
AND SYMPTOMS OF
IMPINGEMENT AND
INSTABILITY
0ARTINGTON 0& AND
"ROOME '(
$ESCRIPTIVE
#ADAVERIC
CADAVERIC SHOULDERS
3PEED # AND
(AZLEMAN "
3YSTEMATIC REVIEW
#LINICAL
%VIDENCE FROM SYSTEMATIC
REVIEWS AND 2#4S ON
INTERVENTIONS FOR SHOULDER
PAIN
4OWHEED 4% ET AL
3YSTEMATIC REVIEW
#LINICAL
2#4S INVOLVING
PATIENTS ON THE
EFFICACY OF .3!)$S FOR
OSTEOARTHRITIS
4OWNSEND ( ET AL
$ESCRIPTIVE
,ABORATORY
NORMAL MALE
VOLUNTEERS
7HEN PAIN ALLOWED
EXERCISES WERE
COMMENCED BELOW
OF ELEVATION
INITIALLY ISOMETRICS BUT
PROGRESSING OVER n
WEEKS THROUGH ISOTONICS
TO ISOKINETICS AND FROM
STRENGTH TO ENDURANCE
! WORK
OR SPORT
SPECIFIC PROGRAMME
WAS THEN COMMENCED
AND CONTINUED FOR AT LEAST
MONTHS 4HIS
WAS FOLLOWED BY A
MAINTENANCE PROGRAMME
$YE WAS ATTEMPTEDLY
INJECTED INTO THE
SUBACROMIAL BURSA
SHOULDER
STRENGTHENING EXERCISES
DERIVED FROM A SHOULDER
REHABILITATION PROGRAMME
USED BY PROFESSIONAL
BASEBALL CLUBS WERE
EVALUATED
/UTCOME
MEASURES
2ESULTS
#RITICAL APPRAISAL CHECKLIST FOR CLINICAL )NCLUDED IN
EFFECTIVENESS STUDIES WHERE APPLICABLE A SYSTEMATIC
REVIEW
3EE FOOT OF TABLE P FOR KEY
%VALUATION WAS BY CLINICAL 2ADIOGRAPHS WERE ALL
9
HISTORY AND EXAMINATION NORMAL
AND INITIALLY RADIOLOGY
)N OF CASES
SYMPTOMS RESOLVED
ALLOWING RESUMPTION OF
PREVIOUS LEVELS OF ACTIVITY
.
4HE REMAINDER REQUIRED
SURGICAL INTERVENTION
HAVING FAILED TO BENEFIT
FROM MONTHS OF
REHABILITATION
.OT A CLINICAL EFFECTIVENESS STUDY
4HE SHOULDERS WERE
OF SUBACROMIAL
SUBSEQUENTLY DISSECTED TO INJECTIONS WERE
REVEAL THE FATE OF THE DYE SUCCESSFUL BUT IN
SHOULDERS OTHER STRUCTURES
WERE INADVERTENTLY
INFILTRATED INCLUDING THE
ROTATOR CUFF IN
$YNAMIC FINE
WIRE INTRAMUSCULAR
ELECTROMYOGRAPHY
.OT A CLINICAL EFFECTIVENESS STUDY
EXERCISES WERE
CONSISTENTLY FOUND TO BE
THE MOST CHALLENGING FOR
EVERY MUSCLE NAMELY
SCAPTION IN THUMBS
DOWN POSITION
FLEXION
HORIZONTAL EXTENSION
WITH LATERAL ROTATION
@PRESS UP IN SITTING
POSITION LIFTING BOTTOM
FROM CHAIR
3TUDY
4YPE
3ETTING
6AN DER (EIJDEN
'*-' ET AL
3YSTEMATIC REVIEW
#LINICAL
9AMAKADO +
$ESCRIPTIVE PRE
TEST
POST
TEST STUDY
#LINICAL
3AMPLE
)NTERVENTION
SHOULDERS IN
PATIENTS MEN
MEAN AGE YEARS
RANGE n WITH 3)3
OF MONTHS DURATION
!TTEMPTED SUBACROMIAL
INJECTION OF ML
MG BETAMETHASONE
ACETATE ML OF
LIDOCAINE RADIOGRAPHIC
CONTRAST MATERIAL USING
A LATERAL APPROACH
/UTCOME
MEASURES
2ESULTS
#RITICAL APPRAISAL CHECKLIST FOR CLINICAL )NCLUDED IN
EFFECTIVENESS STUDIES WHERE APPLICABLE A SYSTEMATIC
REVIEW
3EE FOOT OF TABLE P FOR KEY
2ADIOGRAPHS WERE
TAKEN IMMEDIATELY POST
INJECTION
0AIN ON BOTH .EER
(AWKINS IMPINGEMENT
TESTS WAS EVALUATED
PRE
IMMEDIATELY POST
INJECTION USING A SELF
RATED
POINT SCORE
OF INJECTIONS WERE
JUDGED TO HAVE REACHED
THE SUBACROMIAL BURSA
WERE SEEN TO HAVE
ENTERED THE DELTOID
MUSCLE WERE
INTRA
ARTICULAR
SUBCUTANEOUS
.OT A CLINICAL EFFECTIVENESS STUDY
.O SIGNIFICANT DIFFERENCE
IN PAIN REDUCTION WERE
OBSERVED BETWEEN THE
SUBACROMIAL DELTOID
INJECTIONS
!PPENDIX 4ABLE +EY
$ID THE ARTICLE ADDRESS A CLEARLY FOCUSED ISSUE
7AS THE STUDY DESIGNED IN A WAY WHICH ALLOWED IT TO ADDRESS THE ISSUE
7AS PATIENT SELECTION CARRIED OUT APPROPRIATELY
7AS THE STUDY DESIGNED APPROPRIATELY
7AS THE STUDY CONDUCTED AND ANALYSED APPROPRIATELY
7HAT ARE THE RESULTS
(OW PRECISE ARE THE RESULTS
#AN THE RESULTS BE APPLIED TO MY PATIENT
7ERE ALL CLINICALLY IMPORTANT OUTCOMES CONSIDERED
9
YES
.
NO
UNCLEAR
SHADED CELLS
!RE THE BENEFITS WORTH THE HARMS AND COSTS
NOT APPLICABLE
!PPENDIX
3HOULDER EXERCISES (OME PROGRAMME
!IDE MEMOIRE
9OUR PHYSIOTHERAPIST WILL TELL YOU WHICH OF THESE EXERCISES YOU NEED TO DO HOW MANY TIMES AND HOW
OFTEN AND GIVE YOU DETAILED INSTRUCTIONS 4HE EXERCISES SHOULD NEVER HURT
3TABILISING EXERCISES
4HE IDEA IS TO GET YOUR SHOULDER USED TO SUPPORTING YOU IN LESS LESS STABLE POSITIONS +EEP GENTLY
MOVING YOUR BODYWEIGHT TO ACTIVATE THE STABILISING MUSCLES AROUND YOUR SHOULDER
3ITTING
.OTES
.OTES
+NEELING
.OTES
3TANDING
7ITH A BALL
HANDED
7ITH A BALL
HANDED
.OTES
A 3TARTER STRENGTHENING EXERCISES
B 3TRETCHING EXERCISES
9OULL NEED STRETCHY EXERCISE BAND TO DO THE FIRST EXERCISES 9OUR PHYSIOTHERAPIST WILL GIVE THIS TO YOU
3TRENGTHENING EXERCISE
.OTES
3TRENGTHENING EXERCISE
.OTES
3TRETCHING EXERCISE
.OTES
3TRETCHING EXERCISE
.OTES
-ORE ADVANCED STRENGTHENING EXERCISES
&ORWARD &LEX
.OTES
2OWING
.OTES
4HUMB
DOWN LIFT
.OTES
(ITCH
HIKE
.OTES
0USH UP
.OTES
2OUNDING SHOULDERS
.OTES
!PPENDIX
3UMMARY OF EXERCISE PROTOCOLS FOR SHOULDER IMPINGEMENT SYNDROME
4HE TABLE SUMMARISES EXERCISES DESCRIBED BY VARIOUS AUTHORS AS DISCUSSED IN THE MAIN GUIDELINE
DOCUMENT
-EDIAL LATERAL ROTATORS -2 ,2
!UTHOR
%XERCISE DESCRIPTION
)SOTONIC EXERCISES
"ANG AND $EYLE
s
s
s
"ROX ET AL
s
s
0ERFORM ,2 IN HORIZONTAL EXTENSION IN STANDING USING
STRETCHY BAND
"AND RESISTANCE IS DETERMINED BY REP MAX
0ERFORM SETS X REPS WITH SEC REST BETWEEN SETS
5SING SLING SUSPENSION SUPINE OR SITTING WITH GRADUAL INCREASE OF
ABDUCTION ANGLE
0ERFORM IN STANDING WITH A PILLOW IN THE AXILLA USING STRETCHY BAND
s
-2 AND ADDUCTION BELOW O ELEVATION LOCK INv EXERCISE
,2 ADDUCTION BELOW O ELEVATION BALANCE OF POWERv
EXERCISE
0ERFORM FOR n WEEKS THROUGH ISOTONIC TO ISOKINETIC
-ORRISON ET AL
s
s
s
s
0ERFORM WITH ARM BY SIDE TO EXCLUDE DELTOID
5SE STRETCHY BAND
SETS X REPS ARM HELD IN NEUTRAL FOR SECONDS AFTER EACH REP
#ONTINUE FOR WEEKS
2ODGERS AND #ROSBY
:UCKERMAN ET AL
s
0ERFORM USING FREE WEIGHTS OR STRETCHY BAND IN A COMFORTABLE
RANGE
0ARKER AND 3EITZ
s
s
3UPRASPINATUS DELTOID
"ANG AND $EYLE
s
3CAPTION AGAINST STRETCHY BAND RESISTANCE ELEVATION IN STANDING
AGAINST STRETCHY BAND RESISTANCE
+AMKAR ET AL
s
%LEVATION OF THE EXTERNALLY ROTATED ARM IN THE SCAPULAR PLANE USING
FREE WEIGHTS
-ORRISON ET AL
s
/NLY STRENGTHEN IF COMPLETELY PAIN FREE AND A HIGH LEVEL OF
FUNCTION IS NEEDED
2ODGERS AND #ROSBY
s
5SING FREE WEIGHTS OR ELASTIC RESISTANCE BAND
3CAPULAR 3TABILISATION
"ANG AND $EYLE
s
s
s
3EATED PRESS UP n PERFORM TO FATIGUE OR REPS
0RONE ELBOW PUSH UP PLUS n PERFORM TO FATIGUE OR REPS
2OWING IN STANDING AGAINST THE RESISTANCE OF STRETCHY BAND n
SETS OF REPS WITH SECOND REST PERIOD BETWEEN SETS
"ROX ET AL
s
0USH UP AGAINST A WALL
#ONROY AND (AYES
s
#HAIR PRESS
+AMKAR ET AL
s
s
s
s
s
s
7ALL PUSH WITH EMPHASIS ON PROTRACTION OF THE SCAPULA
3ERRATUS ANTERIOR PUNCH IN SUPINE
3EATED PUSH UP
%ND RANGE SHOULDER FLEXION WITH FREE WEIGHTS IN PRONE
2OWING IN PRONE WITH FREE WEIGHTS
3CAPULAR RETRACTION IN PRONE USING FREE WEIGHTS ARM POSITIONED IN
INTERNAL ROTATION HORIZONTAL ABDUCTION
0ARKER AND 3EITZ
s
3PECIFIC EXERCISES NOT STATED IN LITERATURE BUT RECOMMENDS
STRENGTHENING TRAPEZIUS RHOMBOIDS SERRATUS ANTERIOR WORKING
BELOW ABDUCTION
2ODGERS AND #ROSBY
s
3PECIFIC EXERCISES NOT STATED IN LITERATURE RECOMMEND USE OF
FREE WEIGHTS OR STRETCHY BAND AND PROGRESSION TO OVERHEAD
MOVEMENTS
!PPENDIX
2ECOMMENDATIONS FOR THE PHYSIOTHERAPEUTIC MANAGEMENT
OF SHOULDER IMPINGEMENT SYNDROME &LOW CHART
#ONFIRMED DIAGNOSIS OF SHOULDER IMPINGEMENT
0OSSIBLE PRESENTING SYMPTOMS
0AIN AND INFLAMATION
2ELATIVE REST
AVOIDANCE OF
OVERHEAD OR
AGGRAVATING
ACTIVITIES
5SE OF ICE
n MINUTES
ACCORDING TO SIZE
OF PATIENT
$O NOT USE
PRE
EXERCISE
)N LIAISON WITH
MEDICAL PRACTITIONER
CONSIDER USE OF
.3!)$S
n DAYS
)F SEVERE PAIN
PRESENT OR NO
RESPONSE AFTER
SEVERAL WEEKS
CONSERVATIVE
TREATMENT CONSIDER
STEROID INJECTION
.O MORE THAN
INJECTIONS
)F PATIENT HAS DIAGNOSIS OF CALCIFIC TENDONITIS ALSO CONSIDER USE OF
0%-& X
MINUTES ON
CONSECUTIVE
DAYS
(IGH INTENSITY
CONTINUOUS
ULTRASOUND W
CMDAILY X WEEKS
AND THEN ALTERNATE
DAYS X WEEKS
!VOID RESISTANCE
EXERCISES FOR
WEEKS FOLLOWING
INJECTION
2EDUCED 2/- POWER AND ALTERED
SCAPULOHUMERAL RHYTHM
0ASSIVE
MOBILISATIONS AND
STRETCHING
EXERCISES
3CAPULO
THORACIC
RHYTHMIC
STABILISATION
EXERCISES
!LTERED POSTURE
3TRENGTHENING
EXERCISES
#ORRECTION OF
FORWARD HEAD
POSTURE
!LL EXERCISES SHOULD BE PAIN FREE
s #LOSED CHAIN STABILITY n SITTING STANDING FOUR POINT KNEELING GYM BALL
s 2ESISTANCE n FREE WEIGHTS RESISTANCE BAND
2EFERRAL FOR ORTHOPAEDIC OPINION n )F SYMPTOMS PERSIST
AFTER MONTHS CONSERVATIVE TREATMENT OR MONTHS IF TREATMENT
HAS BEEN CONTINUOUS
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