ANTERIOR SHOULDER PAIN

A 20 year-old male presents to the physiotherapy clinic complaining of right-sided anterior

shoulder pain following a weight-training session during which he had been doing bench
presses.

What questions would you ask in the subjective examination?

1. Exact area of pain - is it at the tip of the shoulder, or referring over the deltoid? - referral to/from
other areas

2. Type of pain - ache/sharp, shooting

3. Constant / intermittent (if constant but varying or intermittent aggravating and relieving factors)

4. Deep/superficial?

5. 24 - Hour picture

6. Any clicking / grating/ feeling of instability / dead arm?

7. Functional limitations

8. Any change in weights or technique?

9. Previous History

Review the following subjective information.

Behaviour of symptoms / BOS:

24 hour picture
Functional limitations
History

(a) BOS

The pain is constant deep ache, localized to the anterior right shoulder. The intensity
is described as 3/10. There is no neck pain or referred pain, numbness, or pins and
needles into the arm. There is occasional clicking. There is a feeling of heaviness in
the arm (a “dead arm” feeling) and there is sometimes a feeling of instability. The
pain is aggravated by activities that require the patient to reach behind him, such as
putting on his seatbelt, and pulling the sheet over him in bed. This elicits a sharp
pain (7/10) but it settles quickly to resting level. Overhead activities are also painful.

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(b) 24 Hour picture 654

AM: when the patient wakes, the shoulder feels stiff and sore but eases within a ½ hour
with some gentle movement and a hot shower

AM-PM: depends on activity but gradually worse by the end of the day

PM: has some difficulty getting to sleep and wakes during the night if he rolls onto the
right shoulder. It eases quickly if he changes position.

Some dressing activities such as putting on a shirt are painful, and he has ceased his
weight lifting and tennis playing.

(c) CHx - this patient had been doing a gym programme four sessions per week for
about one month and over the previous three sessions he increased his weights
significantly. He had not had a trainer check his technique. The session before last he
started to notice some pain after training but it settled within 24 hours. After the last
session three days ago, he woke the following morning with a constant ache in the right
shoulder that has not subsided.

PHx - the patient had a similar episode of shoulder pain when doing a weight-training
programme at school. It settled within a week when he stopped training. He sought no
treatment.

List possible sources of pain/pathology that might be considered at this stage?

Think about the possible mechanism of injury.
The following structures that may be implicated are listed below.

1. Anterior capsule/ posterior capsule

2. Supraspinatus
3. Biceps –long head
4. Subscapularis
5. Pec major/minor
6. Sub-acromial bursa
7. Anterior/superior labrum
8. Acromio-clavicular joint
9. Cervical spine referral

Would you consider there to be any cautions or contraindications when

performing your physical examination or treatment of this patient?

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Predict the main physical findings.

Review the following positive findings from the physical examination

Observation –

slight winging of the inferior angle of the scapula

 tight levator scapulae on right

 right HOH sitting slightly forward (what is normal position of the HOH in the glenoid? Revise
if you don’t know )

Shoulder AROM - Flexion: P1 at 110° P2 @ 130°

 Abduction: P1 at 80° P2 @ 110°

 External Rotation in neutral: P1 @ EOR
 External Rotation @ 90°abduction P1 @ 70°

Impingement Tests - Neer’s test +ve, H-Kennedy test +ve

Muscle-Tendon tests –
Empty can test - negative
Full can test - positive
Yergason’s test - positive

Cervical AROM - normal

Palpation - tender over the long head of biceps femoris

Capsuloligamentous- anterior inferior capsular laxity on the right compared with the left -
posterior capsule tight - horizontal flexion 10° short of neutral before scapula moves.

 Relocation test - positive

Muscle lengths - tight external rotators, pectoralis minor

Muscle weakness - lower trapezius, poor isolated control of GH internal rotation at 90 °

abduction

Labral tests - negative

What would your initial approach to treatment be?

􀂉How would you progress this progamme?