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Shoulder Pain

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Brian Greer

on 1 August 2016

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Transcript of Shoulder Pain

Aytona and Dudley. Rapid Resolution of Chronic Shoulder Pain Classified as Derangement using the McKenzie Method: A Case Series
Setting Shoulder Baselines
Common diagnoses associated with shoulder pain
Subacromial Impingement
Rotator Cuff Injury/Pathology
Acromioclavicular Joint Injury/Pathology
Adhesive Capsulitis
Thoracic Outlet Syndrome
Brachial Plexus/Peripheral Nerve Injury
Labrum Injury/Pathology
Muscle/Tendon Injury
Mechanism of Injury
Symptom Location
Nature of Symptoms
Strength Measurements
ROM Measurements
Appropriate Special tests
Thoracic Spine
Classifications using MDT
Operational definitions

Pattern 1
Pattern 2

Pattern 3
Dysfunction Syndrome

- Internal dislocation of articular tissue of unknown origin that causes a disturbance in the normal resting position of the affected joint surface, resulting in pain and restriction to movement

- Normal mechanical deformation of structurally impaired contractile or articular tissue that results in pain

- No abnormal pathology, characterized by intermittent pain that is caused by abnormally loading normal tissue for a prolonged period

- Anything that does not meet the criteria of the above mechanical classifications (recent trauma, post-surgery, chronic pain state, or mechanically inconclusive)
Flexion 180 degrees

Extension 60 degrees

Internal Rotation 90 degrees

External Rotation 100 degrees

Abduction 180 degrees

Horizontal Abduction 90 degrees

Horizontal Adduction 50 degrees
Cervical Spine
Thoracic Spine
- Patient experiences any length of time without pain

- Patient never has pain relief. Symptoms are always present, even at rest
- Symptoms vary in terms of severity, duration, provocative positions, or activities associated with pain

- Patient experiences similar pain with the same activity/position, every time
Time since onset
- Determines possibility of classifying as derangement, dysfunction, or inflammatory.
Symptoms & Findings
Limited abduction/flexion

Pain and limitation with internal rotation and extension

Reductive Repeated Movement
Begin with most obstructed direction (Internal rotation or Extension)

If Internal rotation is severely limited - start with Extension
Symptoms & Findings
Limitation in abduction and extension

No limitations in extension or internal Rotation

Reductive Repeated Movement
Horizontal adduction, with self overpressure

Can progress with therapist overpressure
Same findings as pattern 1
Should be considered if symptoms plateau, or get worse with pattern 1 treatment

Repeated Movement
External rotation in 90 degrees of shoulder and elbow flexion
If symptoms do not change, progress to internal rotation in same position
Change starting position to horizontal adduction or abduction
Did you notice anything specific that could have caused this pain, or did it start for no apparent reason?
Did this pain come on as a result of trauma?
What position was the shoulder in?
What happened exactly?

If it started for no reason specifically, think back to before it started. Were you involved in any accidents prior to that? Any history of neck or shoulder pain in the past?
Gross strength testing can tell you a lot

External and Internal Rotators


Should and Elbow Flexors

Shoulder Extensors

Scapular Stabilizers

Thoracic Extension
Thoracic Rotation
Mechanical deformation of structurally impaired soft tissue which results in pain and limited range of motion.
Subcategorized into articular dysfunction and contractile dysfunction
Treatment involves progressive tissue loading to remodel the articular or contractile tissue
Shoulder Pain
Diagnosis and Treatment using the McKenzie Method (MDT)
Brian Greer
Julia Tranquillo

Setting cervical baselines is necessary before repeated movement begins

These baselines should be checked after repeated movement testing to monitor any changes in symptoms
Clinical Decisions Based on
Radiographic Findings
"High prevalence of age related changes in asymptomatic subjects emphasizes the danger of making operative decisions based solely on MRI findings"

"There is a higher prevalence in older individuals of rotator cuff tendon tears that cause no pain or decrease in activities of daily living"
Kato et al. Normal morphology, age-related changes and abnormal findings of the cervical spine. Part II: Magnetic resonance imaging of over 1,200 asymptomatic subjects.
Schibany et al. Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study.
Spine vs. Shoulder Differential
"Despite all the factors that suggested the symptoms originated from the shoulder, when reductive mechanical forces were applied to the cervical spine, these abolished the symptoms [at the shoulder]."
May and Menon. Shoulder pain: differential diagnosis and therapy extremity assessment- a case report
"Change in shoulder pain or active shoulder range of motion following cervical mobilizations indicate that treatment directed towards the asymptomatic cervical spine may expedite the recovery."
McClatchie et al. Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults
Clinical Applicability of Shoulder Special Tests
"There is no consistent evidence that any examination procedure used in shoulder assessment has acceptable levels of reliability."
"Overall, most tests for rotator cuff pathology were inaccurate and cannot be recommended for clinical use."
May et al. Reliability of Physical Examination Tests used in the Assessment of Patients with Shoulder Problems: A Systematic Review
Hughes. Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review
Aytona and Dudley. Rapid Resolution of Chronic Shoulder Pain Classified as Derangement using the McKenzie Method: A Case Series
Case Reports in the Literature
Kidd. Treatment of Shoulder Pain Utilizing Mechanical Diagnosis and Therapy Principles
Case Reports in the Literature
Aina and May. Case Report: A Shoulder Derangement
- Neer's Impingement Test
- Hawkin's Kennedy
- Painful Arc
- Yocum Impingement Test
- Drop-Arm Test
- Empty Can Test
- Speed's Test
- Yergason's Test
- Anterior Apprehension Test
- Sulcus Sign
- Biceps Load Test II
- O'Brien's Test
- Adson's Sign
Horizontal Adduction
Extension with Internal
Internal Rotation
with Towel
Pattern 3 is rare
External rotation in 90 degrees of flexion
- Patient compliance regarding frequency of exercise

- Incorrect form while performing

- Failure to establish correct mechanical classification

- Failure to get the patient to end range

- Using MDT as a treatment system not a classification system (you cannot treat something you do not first understand)

Typical reasons for failure when using MDT
Full transcript