Stanbridge - T4 - TE2 - W6 - The Shoulder & Shoulder Girdle (Part 1)

Therapeutic Exercise II: The Shoulder and Shoulder Girdle

• This course covers the anatomy and function of the shoulder girdle
• Students will learn about common shoulder pathologies that benefit from therapeutic exercise interventions.
• These interventions include hypomobility, hypermobility, and soft tissue overuse conditions.
• Students will learn how to create and modify therapeutic exercise programs for musculoskeletal, soft tissue, and joint lesions, based on the healing stages of tissue.
• The course will include common surgical procedures and precautions for conditions like hypomobility and instability.
• Students will learn about post-operative management goals and interventions for shoulder and shoulder girdle dysfunction at different rehabilitation phases.
• Students will learn how to demonstrate exercise progressions to improve range of motion (ROM), muscle performance, and functional use of the shoulder and shoulder girdle.

Outline of Topics

• Structure and function of the shoulder girdle
• Hypomobility: nonoperative management and TSA
• Hypermobility: instability of the GH joint
• Painful biomechanical shoulder syndromes

Structure and Function of the Shoulder Girdle

• Joints of the shoulder girdle: Glenohumeral (GH) joint, Acromioclavicular (AC) joint, Sternoclavicular (SC) joint
• Shoulder girdle function
• Force couples of shoulder complex: Balance, mobility, and stability, with diagrams showing angles and relationships

Shoulder Girdle Complex

• Synovial joints: Glenohumeral (GH) joint, Acromioclavicular (AC) joint, Sternoclavicular (SC) joint
• Functional articulations: Scapulothoracic articulation (ST), for greater shoulder mobility

Anatomy Review

• Glenohumeral joint structure (anatomical diagram)
• Acromioclavicular and sternoclavicular joint structures (anatomical diagram)
• Clavicle, scapula, humerus, sternum, and supporting structures

Glenohumeral Joint

• Incongruous ball and socket joint
• Tri-axial joint
• Lax joint capsule
• Supported by:
  • rotator cuff (RTC)
  • glenohumeral ligaments (superior, middle, inferior)
  • coracohumeral ligaments
• Glenoid fossa: shallow, deepened by fibrocartilaginous lip
• Humeral head: 3-4x larger than glenoid fossa
• Glenoid labrum: a structure that deepens the glenoid fossa, providing stability, and an attachment site for the joint capsule
• Diagram of Glenoid Fossa (includes the muscles and ligaments)

Glenohumeral Joint: Stability

• Provided by static and dynamic restraints
• Static: bony anatomy, ligaments, glenoid labrum, and adhesive/cohesive forces
• Dynamic: RTC tendons blend with ligaments and glenoid labrum. Contraction tightens static restraints to enhance stability
• Coordinated response of the RTC muscles & biceps/triceps
• Long head of Biceps: Stabilizes against humeral elevation; resists torsion when in abduction & ER; contributes to humeral depression
• Long head of Triceps: Inferior shoulder support

Acromioclavicular Joint

• Plane, triaxial joint
• May or may not have AC disc
• Reinforced by superior and inferior AC ligaments
• Supported by coracoclavicular ligaments
• No dynamic support

Acromioclavicular Joint: Arthrokinematics

• Acromion: concave facet
• Clavicle: convex facet
• When scapula moves, acromial surfaces slide in same direction
• Motions affecting the AC joint
  • Upward rotation
  • Downward rotation
  • Winging of vertebral border
  • Tipping of inferior angle

Sternoclavicular Joint

• Incongruent, triaxial, saddle-shaped joint
• Has a disc
• Stability provided by
  • Anterior and posterior SC ligaments
  • Interclavicular ligaments
  • Costoclavicular ligaments

Sternoclavicular Joint: Arthrokinematics

• Clavicle motions as a result of scapular motions.
  • Elevation
  • Depression
  • Protraction
  • Retraction

Clavicular Elevation and Rotation

• Posterior rotation of clavicle occurs as an accessory motion when humerus is elevated above 90 degrees.
• Cannot occur in isolation
• Coracoclavicular ligament taut for passive stability

Scapulothoracic Articulation

• Motions:
  • Elevation, depression
  • Adduction, abduction
  • Upward, downward rotation
  • Protraction
  • Retraction
• Additional motions: tipping/tilting (anterior/posterior), winging (medial border lifts away from rib cage)

Subacromial Space/Suprahumeral Space

• Coracoacromial arch: acromion & coracoacromial ligament
• Structures: subacromial/subdeltoid bursa, supraspinatus tendon, long head of biceps tendon

Subacromial Space/Suprahumeral Space: Compromise

• Causes: faulty posture, muscle function, joint mechanics, structural abnormalities (Type I, II, III acromion), injury to soft tissue
• Outcome: Impingement syndrome

Shoulder Girdle Function

• Force couple review: deltoid-rotator cuff, trapezius/serratus anterior, anterior-posterior rotator cuff
• Important for balance and stability (diagram of forces)

Deltoid-RTC Relationship

• Deltoid leads to upward translation of humerus.
• Downward force/translation, and stabilizing producers:
  • Infraspinatus
  • Teres minor
  • Subscapularis
• Supraspinatus: significant stabilizing, compressive, slight upward translation effect on humerus with UE elevation
• What is another humeral depressor? (See slide for answer)

Trapezius/Serratus Anterior

• Work together for scapular upward rotation (UT, LT, SA)
• Assists in elevation
• Lack of function leads to increased impingement due to lack of scapular rotation

Anterior/Posterior RTC

• Keeps humeral head properly positioned in glenoid
• Includes: subscapularis, infraspinatus, teres minor
• Opposes anterior-posterior glenohumeral joint translation

Shoulder Girdle Function: Failure

• Interruption of deltoid-RTC coordination
• Leads to tissue microtrauma, compression, or overuse of soft tissues causing shoulder dysfunction

Scapulohumeral Rhythm

• 3 phases where 180 degrees of elevation are assisted
• General 2:1 ratio (GH vs. scapula)
• Discrepancies in 1:1 vs 2:1 ratio in sources
• Phases:
  • Phase 1: 0-30° abduction, 0-60° flexion. Primarily GH motion, scapula finding stability
  • Phase 2: 30-90° degrees (depending on motion). Improved joint congruency as length-tension relationship of muscles is maintained (approaches 1:1 ratio)
  • Phase 3: Last 90°. Dominated by glenohumeral motion. GH joint must ER to clear subacromial arch

Review (Questions)

• How does forward head and shoulder position affect the scapula and glenohumeral joint position?
• What are the various motions of the scapula?
• What are the major downward and upward rotators of the scapula?
• What is the importance of the long head of the biceps and triceps?
• Why is ER of the humerus with shoulder elevation important?

Shoulder Pathology and Management

• Joint Hypomobility: Non-operative management, surgery & post-operative management
• Glenohumeral Joint: Surgery & post-operative management
• Shoulder Instabilities: Non-operative, management; surgery & post-operative management
• Painful Shoulder Syndromes: Non-operative management (RTC, impingement syndromes); surgery & post-operative management

Shoulder Pathologies General Interventions

• Hypomobility: Restore Mobility/ROM
• Hypermobility: Restore Stability (strength)
• Painful disorders: Restore proper biomechanics

GH Joint Pathologies: Management

• Will initially be treated conservatively.
• Often involves pharmacology and active physical therapy.
• Includes therapeutic exercise

Joint Hypomobility: Non-operative Management

• Hypomobility can occur in any of the shoulder complex joints. - Glenohumeral (GH) joint - Acromioclavicular (AC) joint - Sternoclavicular (SC) joints
• Causes: rheumatoid arthritis, prolonged immobilization, traumatic arthritis, osteoarthritis, idiopathic frozen shoulder

GH Joint Hypomobility

• Restricted GH joint mobility due to: Rheumatoid arthritis, prolonged immobilisation, traumatic arthritis, Osteoarthritis, idiopathic frozen shoulder

Glenohumeral Osteoarthritis

• Description of the disease & characteristics
• Diagram/Images of the condition

GH Joint Arthritis: Clinical Signs & Symptoms

• Acute Phase: Pain, muscle guarding limits motion (ER, abduction), pain may radiate below elbow, disturb sleep
• Swelling usually not detectable
• Sub-acute Phase: Capsular tightness begins to develop, Limited motion pattern, pain at end of motion.
• Chronic Phase: Progressive restrictions in GH capsule, further limited motion and joint play. Significant loss of function (reaching overhead, out to side, behind back), aching in deltoid region

Idiopathic Frozen Shoulder/Adhesive Capsulitis

• Average age of onset: 40-65 years old
• Characterized by gradual onset of pain, restricted movement
• Synovial inflammation followed by fibrosis (capsuloligamentous complex)
• Self-limiting clinical entity, progresses through stages
• Primary (idiopathic): unknown cause
• Secondary: known cause (e.g., post-op, immobilisation)
• Stages: Pre-adhesive, Freezing, Frozen and Thawing (detailed clinical signs & symptoms of each) – Average time from onset to recovery

APTA Guidelines- Adhesive Capsulitis 2013

• Corticosteroid injections
• Patient education
• Stretching exercises
• Modalities
• Joint mobilization
• Translational manipulation (anesthesia)

GH Joint Hypomobility Impairments

• Night pain, disturbed sleep during acute flares
• Pain with motion; pain at rest during acute flares
• Decreased joint play and ROM in capsular pattern
• Decreased arm swing during gait
• Possible postural compensations: (protracted & anterior tilted scapula, elevated, protected shoulder)
• Excessive scapular motion
• Muscle performance:
  • GH muscles: general muscle weakness and poor endurance
  • overuse of scapular muscles
• Difficulty lifting weighted objects
• Inability to reach overhead, behind head, out to side, behind back
• Limited ability to sustain repetitive activities

GH Joint Hypomobility: Non-Operative Management

• Acute Phase (Protection):
  • Control Pain, Edema, Muscle Guarding
  • Maintain Soft Tissue and Joint Integrity and Mobility
    • Pendulum (Codman's)
    • PROM
    • Passive joint distraction, Grade I, II joint mobilizations
    • Gentle muscle setting
  • Maintain Integrity and Function of Associated Regions
    • Hand exercises
    • Cervical ROM

PROM to Relieve pain and pressure in the joint: Pendulum (Codman) Exercises

• Passive motion
• Move your body/hips not your arm
• No weight: gentle distraction of GH joint
• With weight: Grade III (stretching) distraction force

Passive Exercises to AAROM

• External Rotation (elbow remains next to torso)
• AAROM: Only assist active motion necessary

Exercise Examples: PROM, AAROM: Flexion, Abduction

• Encouraging ER during shoulder elevation

S-Assisted Shoulder Elevation

• Supraspinatus is more active with seated pulley systems
• Performed when patient is released from PROM phase
• Ensure GH joint is in ER when moving overhead

GH Joint Hypomobility: Non-operative Management; Subacute Phase

• Control pain, edema, joint effusion
• Functional activities
• ROM: AAROM → AROM resistance
• Progressively increase joint and soft tissue mobility - Passive Joint Mobilization - Self-Mobilization - Manual Stretching - Self Stretching

GH Joint Hypomobility: Non-operative Management; Controlled Motion Phase

• Inhibit Muscle Spasm & Correct Faulty Mechanics
  • Teach proper mechanics
  • Gentle joint oscillation
  • Sustained caudal glide
  • GH IR and ER strengthening
  • Protected WB
• Improve Joint Tracking (MWM)
• Improve Muscle Performance (Posture, trunk stability)

Interventions to Increase Motion: Mobilization with Movement: Posterior Lateral Glide

• Patient performs active elevation while a sustained posterior glide is performed.

Exercises to increase motion: Self Caudal Glide (GH Joint)

Exercises to increase motion: Self Anterior Glide

Exercises to increase motion: Self Posterior Glide

Self Stretching to Posterior Shoulder

• Stretch posterior capsule and external rotators, increase internal rotation
• Maintain proper spine posture

Exercises to increase motion: Subscapularis Stretch

• Stretching into ER
• Maintain correct abduction
• Chest up for proper positioning

Exercises to increase motion: Pectoralis Major Self Stretch

• Clavicular portion of pec major biased, sternal portion of pec major biased

Exercises to increase motion: Levator Scapulae Self Stretch

• Using upward rotation of the scapula to stretch.
• Using depression of the scapula to stretch

Exercises to increase motion: Sleeper Stretch

• To increase IR

GH Joint Hypomobility: Non-operative Management; Chronic Phase

• Progressively increase flexibility and strength
• Continue with strengthening
• Prepare for functional demands (sport & work specific training)

GH Joint Hypomobility: MUA

• Manipulation Under Anesthesia (used in cases with lack of improvement by non-operative treatments)
• Initially treated as an acute lesion
• Arm kept in overhead and ER position
• Immediate joint mobilization, PROM daily
  • Emphasize inferior glide
  • Emphasize abduction, ER
• Positioning: in ER and abduction (to avoid capsular pattern)

Review (Questions)

• What is the capsular pattern of motion loss for the glenohumeral joint?
• When does the capsular pattern of motion loss typically occur in a joint?
• What are 3 appropriate interventions for glenohumeral arthritis in the acute phase of healing?
• What are some causes of AC joint pathology?
• What motions of the shoulder will be limited in the acute phase of AC joint healing?

Glenohumeral Joint Pathology & Post-op Management

• Arthroplasty: Any joint procedure (with or without implant), used for pain relief and improved function.
  • Excision Arthroplasty
  • Excision Arthroplasty w/ implant
  • Interposition Arthroplasty
  • Joint Replacement Arthroplasty

Joint Replacement Arthroplasty

• Total Joint Replacement: Resection of both affected surfaces & replacement with artificial components.
• Hemi-replacement Arthroplasty: Resection of one surface, Indications include late-stage arthritis/femoral neck & proximal humeral fractures

Total Shoulder Arthroplasty (TSA)

• Surgical Procedures (description)

Glenohumeral Joint Surgery

• TSA, rTSA, Hemiarthroplasty (procedures & outcomes)

GH Arthroplasty: Post-Operative Management; Key Points

• ROM Goals for TSA* and rTSA (range differences)

GH Arthroplasty: Post-Operative Management—Exercise Progression

• Think about the anatomical structures involved in the surgery, and identify the surgical goals.
  • What was cut?
  • What was repaired?
  • What is the post-operative time frame?
  • What is the patient telling you?
  • How is the patient responding to treatment?
  • Use protocols to assist in guiding your exercise program

GH Arthroplasty: Post-Operative Management—Immobilization

• Sling or splint for reattached & repaired tissues
• Removed for exercise & bathing ASAP
• Immobilization time frame (usually 4-6 weeks, up to 8-12 weeks)

GH Arthroplasty: Post-Operative Management—Positioning

• Arm in slight flexion (10-20°) with slight abduction
• Elbow flexion at 90°
• Forearm & hand resting on abdomen/pillow
• Maintain scapula in a resting position

GH Arthroplasty: Post-Operative Management

• Correct faulty posture (will affect shoulder outcomes)

GH Arthroplasty: Post Operative Management: Table 17.2—TSA vs. rTSA

• (Table of comparison between TSA & rTSA in post-operative management)

GH Arthroplasty: Post Operative Management- Maximum Protection Phase

• Hospitalization (3-4 days), precautions, HEP
• Control pain & inflammation
• Maintain adjacent joint mobility
• Restore/maintain shoulder mobility (progression)
• Minimize muscle inhibition, guarding, and atrophy

Precautions: Maximum Protection Phase

• ROM (PROM, AAROM)
• No extension/horizontal abduction beyond neutral
• No lifting with involved arm
• No weight bearing
• No driving for 4-6 weeks
• Wear sling as indicated (Specific precautions for TSA and rTSA)

Gentle Post-op AAROM Exercise: Gear Shift Exercise

Criteria for Progression to Moderate Protection/Controlled Motion Phase (TSA)

• PROM, Elevation to 90, ER to 45, IR to 70 (in plane of the scapula), Minimal pain.
• No pain during resisted isometric IR
• Able to perform waist-level ADLs with no/minimal pain for rTSA
• Tolerance to AAROM, ability to isometrically activate deltoid and periscapular muscles while position in scapular plane.

Exercise: Moderate Protection/Controlled Motion Phase

• 4-6 weeks → 12-16 weeks
• Control pain and inflammation
• Progressively increased ROM
• Develop active control & dynamic stability (specific exercises noted for rTSA)

rTSA Special Considerations; Moderate Protection Phase

• No WB through arm until 12 weeks
• Pain-free submaximal isometrics to repaired muscles and subscapularis
• Dynamic low-resistance exercises for elbow, wrist, and hand
• Late in phase: RTC strengthening, strengthening scapula and shoulder muscles (progress supine→sitting)

Submaximal Isometrics: Flexion, Abduction and ER

• Exercises for isometric muscle activation

Isometric or Dynamic Manual Resistance to Scapular Muscles

• Exercises using manual resistance for scapular muscle activation

Dynamic Manual Resistance for ER/IR Muscles

• Exercises with manual resistance

Isometric Resistance in Scapular Plane

• Exercises for scapular muscle activation
• Can be performed at various angles with elevation depending on the symptoms and findings

Isometric Stabilization Exercise

• More advanced than "muscle setting"
• Apply resistance in varying sequence for flexion/extension, abduction, adduction, ER/IR.
• Can be performed for single arm without wand.
• Eyes open vs eyes closed for different challenges to the exercises

GH Arthroplasty: Post Operative Management; Criteria to Progress to Minimal Protection/Return to Function Phase

• Pain-free PROM/AAROM
• Flexion to at least 130-140 degrees
• Abduction to 120 degrees
• ER to 60, IR to 70 in plane of scapula
• Active elevation of UE against gravity to 100-120 degrees with proper mechanics, MMT: 4/5 for RTC and deltoid.

GH Arthroplasty: Post Operative Management; Minimum Protection/Return to Function Phase

• Continue to improve or maintain shoulder mobility, neuromuscular control & muscle performance.
• Return to most functional activities

CKC Scapular and GH Stabilization Exercises

(B) In minimal WB position, unilateral on less stable surface

Review (Questions)

• What is the difference between TSA and r-TSA?
• What muscle is retracted and reattached with a TSA?
• Based on the protocol in the Kisner, what exercises are appropriate for a patient s/p r-TSA at s/p post-op 6 weeks? Write them as you would in the objective section of a SOAP note.

Outline (recap of all previous outlined topics regarding shoulder girdle and instability)

Shoulder Instability (Hypermobility)

• Atraumatic hypermobility (due to generalized connective tissue laxity or microtrauma related to repetitive activities)
• Traumatic hypermobility (high force event(s) compromising stabilizing structures, often dislocating GH joint) - Unidirectional - Multi-directional
• Atraumatic Hypermobility: Unidirectional Instability
  • Anterior, posterior or inferior
  • Due to physiologic laxity of connective tissue, repetitive microtrauma
  • Humeral head may continue to dislocate or sublux
  • Can lead to progressive degeneration and subsequent tearing of supportive structures

GH Instability

• Anterior: Excessive anterior humeral head translation from forces against the arm when abducted/externally rotated
• Posterior: Can occur from repetitive or forceful forces against a forward flexed, adducted, internally rotated humerus
• Inferior: Typically results from RTC weakness or paralysis (hemiplegia)
• Multidirectional: Occurs when GH joint stability is compromised in more than one direction

Recurrent Dislocations

• With significant ligamentous and capsular laxity, one or multidirectional subluxations/dislocations occur, reproducing the forces causing instability.
• Voluntary dislocations (worse prognosis), can dislocate without apprehension & minimal discomfort.
• Highest rate of recurrence after 1st traumatic dislocation in younger populations (<30 years old).

Closed Reduction of Anterior Dislocations: Management

	- Acute Phase (Protection): Protect healing tissue, promote tissue health
	- Subacute Phase (Controlled Motion): Provide protection, Increase shoulder mobility, Increase stability/strength of RTC & scapular muscles
	- Chronic Phase (Return to Function): Restore functional control, return to activity

Closed Reduction of Posterior Dislocations: Management

• Same general rehab as anterior/inferior dislocations, EXCEPT:
• Avoid humeral flexion with adduction and IR during acute & healing phases; posterior glide is contraindicated once mobilization is allowed.

External Rotation Evidence

• Infraspinatus activation greater at lower shoulder abduction angles
• Teres minor activation unaffected by shoulder angles
• Best exercise: Teres minor + infraspinatus = side-lying shoulder ER, Standing ER @ 45° Abd, Prone ER @ 90° - Adding towel roll between elbow & trunk increases ER muscle EMG 20-25%

Muscle Activation Evidence

• Use a towel roll to target the specific muscle being focused on in the exercises.
• Variety in exercise programs

Internal Rotation Evidence

• IR at 0 degrees abduction: very stable, add a towel roll for 20-25% increased activity
• IR at 90 degrees abduction: unstable position, less pectoralis activity, enhances scapular position, helps isolate subscapularis
• IR diagonal exercise—more functional (not PNF)

Abduction in Plane of the Scapula

• Standing “Full Can”: better than empty can for isolating supraspinatus from deltoid, improved GH mechanics, scapular plane: 30 degrees anterior to the frontal plane
• Prone full can: Greater EMG of posterior deltoid vs middle, decreases superior shear force, prone position activates scapular muscles

Deltoid Evidence

• Posterior deltoid: not a large roll; high activity with prone full can, 60º abduction: all deltoid muscles cause instability, 60º scaption: deltoid muscles contribute to stability
• Middle deltoid: most significant impact on superior head migration, high activity with empty can
• Anterior deltoid: effective abductor at start of full can, not effective abductor at start of empty can, large superior humeral migration pull

Serratus Anterior Evidence

• Serratus function: prevents scapular winging & anterior tilt, serratus + upper/lower traps = upward rot of scapula
• Top activation activities: push with plus, dynamic hug, supine punch

Lower Trapezius Evidence

• Top activation exercises: prone full can, prone ER at 90°, prone horizontal abduction at 90°

Rhomboids and Levator Scapulae Evidence

• Best exercises for activation: scapular abduction above 120° with ER, prone horizontal abduction at 90° abduction with IR and ER, prone rowing, prone extension from 90° flexion

Prone Scapular Retraction against resistance

• Scapular retraction (setting) towards spine should be initiated prior to horizontal abduction

Horizontal Abduction & Scapular Retraction

• Scapular retraction (setting) first.
• Thumbs facing ceiling: emphasize strengthening of the middle and lower trapezius.

Surgical Intervention for capsular instability

Capsule Stabilization & Reconstruction

• General rehab goals: restore balance of joint stability and functional motion while protecting repaired tissues, amount of immobilization and progression depend on surgery type, type of injured tissue, severity of injury, tissue fixation & quality.
• Restore ROM & Strengthening dynamic stabilizers.

Precautions following anterior GH stabilization

• Limit ER, horizontal abduction & extension during first 6 weeks
• No vigorous stretching to increase ER for 8-12 weeks.

Painful Shoulder Syndromes: Non-Operative Management

• Impingement, tendonitis/tendinopathy, Bursitis —Descriptions, causes & characteristics of various types of painful shoulder conditions; and management.

Painful Shoulder Syndrome: SPS/Impingement

• Subacromial pain syndrome/impingement: Subacromial space = mechanical compression and irritation of the RTC and subacromial bursa; within suprahumeral space.
  • Pain with overhead reaching
  • Painful arc (mid range elevation)
  • Positive impingement tests

Intrinsic Impingement (RTC Disease)

• Intrinsic factors: compromise musculotendinous structures
  • Vascular changes in RTC tendons, tissue tension overload, collagen disorientation and degeneration; in people over 40, may progress to RTC tears

Extrinsic Impingement

• Mechanical wearing of the RTC against the anterior/inferior 1/3 of the acromion, often caused by decreases in subacromial space due to anatomical and biomechanical factors

Acromion Shape

• Having an acromion shape of Type III would lead to extrinsic impingement

Faulty Posture

• Forward head, thoracic kyphosis, forward tilt & downward rotation of scapula, relative abduction, IR of the humerus (how it might lead to impingement) (diagram)

Scapular Stability & Posture

• Slouched posture alters the relationship of the scapula and humeral muscles, altering mechanics of the GH joint

Roundback/Forward Head Faulty Posture

• Summary diagram with various factors that influence this faulty posture.

Tendinopathy

• Function of tendons - transmitting muscle forces to bone
• Causes & phases of tendinopathy healing.
  • Inflammatory phase (1-7 days);
  • Repairing phase (Day 5 to 7-5 weeks);
  • Remodeling phase (6 weeks -10 weeks)
  • Maturation phase (10 wks-1 year)
• Supporting evidence lacking for eccentric exercises for shoulder

Painful Shoulder Syndromes; Tendonitis/Bursitis

• Supraspinatus tendonitis
• Infraspinatus tendonitis
• Bicipital tendonitis
• Subdeltoid bursitis
• Subacromial bursitis

Supraspinatus Tendonitis

• Usually at the musculotendinous junction
• Painful arc; impingement tests
• Pain with palpation (inferior to the acromion)

Infraspinatus Tendonitis

• Usually near musculotendinous junction
• Painful arc w/ overhead/forward/cross body motions
• May be due to deceleration injuries (throwing motions)
• Pain w/ palpation (inferior to posterior corner with horizontal add/ER)

Bicipital Tendonitis

• Lesion of long head of bicep tendon (within bicipital groove)
• Swelling in the bony groove
• Positive Speed's Test
• Pain with bicipital groove palpation - possible rupture or dislocation

Bursitis

• Subdeltoid/subacromial bursa inflammation
• Same acute phase symptoms as supraspinatus tendonitis
• No symptoms present with resisted movement (once acute phase subsides)

Other Musculo-tendinous Problems

• Injury, overuse or repetitive trauma that can occur in any muscle
  • Pain with palpation of injured tissues, restricted motion and pain with muscle lengthening; pain & weakness during muscle contraction
  • Pectoralis minor, short head of biceps, coracobrachialis (microtrauma in racquet sports)

Review (Questions)

• What are typical patient complaints with GH impingement?
• What are appropriate exercises to perform for subdeltoid bursitis, proximal bicipital tendonitis, or supraspinatus tendonitis in the acute phase of tissue healing? Subacute?