Interventions and Outline Management of Shoulder . EBM Rotator Cuff . Evidence, pt values, clinical expertise . Management . General treatment approach Lori A Michener PhD, PT, ATC, SCS . Specific Interventions Virginia Commonwealth University . Judging improvement Medical College of Virginia . Consensus and Controversies RichmondRichmond,, VA . Questions and Answer time…

Not what you do, but how you sell it Evidence Based Medicine (Scheele J, BMC MSK, 2011; Carroll LJ, J Rheumatol,Rheumatol, 2009) . Evidence . Expectation of recovery . Study results - response of the majority . Your expectations for this episode of pain? . Evidence: ‘first choice’ of treatment . Do you think your injury will get better, . Pt not improvingimproving––your pt is in the minority? worse, stay the same? . Clinical expertise . Do y ou think PT w ill help this episode? . Valuable, however should not be used IN . Any interventions in particular helpful? PLACE of evidence until evidence used ** What to do with the answers? . “Selective memory” –eyewitness to a crime . Patient preference and values PT – a sales job –not ‘what’ you do, but . More important than you think! how you sell it.

Complaint of “Shoulder Symptom” Level 1 Screen History (A), Basic PE (B), Red Flags (C) Treatment Categories

Non-shoulder origin of sx Shoulder origin of sx Impingement Instability Adhesive Other Syndrome Capsulitis e.g, Level 2 Specific Phys Exam (D) “Control” “Too loose” “Too Tight” fracture MdilDMedical Dx Rotator Cuff / Frozen Glenohumeral Impingement Shoulder Instability Level 3 - Subacromial Space Disorder Rehab Dx - Anterior – Superior Shoulder pain High Irritability Moderate Irritability Low Irritability Systematic Reviews of SAIS/ Sh P Treatment Approach – EvidenceEvidence--BasedBased:: ((HanrattyHanratty CE, 2012, Littlewood C, 2012, Brudvig TJ, 2011; Marinko LN, 2011; Kromer TO, 2009; Kuhn JE, 2009; Ainsworth, 2007; Michener LA, 2004; Bottom Line Up Front DesmeulesDesmeules,, 2003) . Unsure (limited or no evidence): • 99-- 16 RCTs . Scapular taping –immed–immed.. effects only •  pain &  function / disability: . Scapular motor control and stabilization • ExerciseExercise-- stretch & strengthen/ MC exercise focus • Exercise + manual therapy to the . Core stability training glenohumeral joint and spine . Eccentrics focus • Home exercise programs • Passive treatments: not recommended . Frequency of treatment • US: not effective . Progression of treatment . Dose of exercise and manual therapy

Complaint of “Shoulder Symptom” High Irritability Moderate Irritability Low Irritability Level 1 (3/5 to categorize) (3/5 to categorize) (3/5 to categorize) Screen History (A), Basic PE (B), Red Flags (C) • High Pain (> 7/10) • Mod Pain (4-6/10) • Low Pain (< 3/10) • night or rest pain • Night or rest pain • Night or rest pain Non-shoulder origin of sx Shoulder origin of sx • consistent intermittent • none • Pain before end • Pain at end ROM • Min pain with ROM •AROM ≈ PROM overpressure Level 2 • AROM < PROM • Mod Disability • AROM equal to Specific Phys Exam (D) •(DASH, ASES) MdilDMedical Dx • High Disability PROM •(DASH, ASES) • Low Disability Rotator Cuff / Frozen Glenohumeral Rx focus: •(DASH, ASES) Impingement Shoulder Instability Rx focus: • pain reduction • improve Rx focus: Level 3 • pain reduction impairments • restore higher Rehab Dx • improve basic demand functional functions (self-care, activities (work High Irritability Moderate Irritability Low Irritability domestic tasks) demands, recreational and leisure activity)

Ant or General Spine Dose - Evidence Capsular Posture Laxity . HighHigh--dosedose vs lowlow--dosedose chronic imping.imping. ((OsterasOsterasH, Open Ortho, 2010; Osteras H, Physiother Res Int,Int, 2010) Scapular Ms Strength . HiHi--dose:dose:  pain & function 3, 6 & 12 months post RCD / imp. Treatment . HighHigh--dose:dose: Ant Sh Tightness Category . 11--hrhr session, 9-9-1111 exercises, 3 x 30 reps, RC Strength 1000 reps per treatment, aerobic ex . Low –dose:–dose: 2 x 10 reps/ exercise Post Sh Tightness Humeral Scapular kinematics kinematics Clinical Trial of Rehab for ImpingImping.. Key Impairments (Tate AR, McClure PW, Young IA, Salvatori R, Michener LA. JOSPT, 2009) . Tightness Standardized impairment evidenceevidence--basedbased Program: . Weakness ––ExerciseExercise . Scapular Dysfunction – Manual therapy: shoulder and spine – PiPatient educat ion – Home exercise program Standardized approach for dose, progression, and frequency Use this as the framework for defining the treatment approach

Tightness Upper thoracic extension stretch Flexibility: Self Stretching Lie on top of a Upper thoracic extension stretch vertically placed Doorway pectoral stretch towel under the Crossbody stretch thoracic spine Shoulders ER Shoulder flexion stretch – Supine (phase 1)  standing (phase 2,3) Shoulder ER stretch Shoulder IR stretch (towel)

Crossbody and Shoulder flexion Pec stretch stretch Patient Education: Sleeping Shoulder IR and ER stretch posture

Strengthening and Motor Control Scapular Muscle . Upper Trapezius . Is it strengthening or motor control? . REDUCE activity during arm elevation Likely a combination . Motor control can help –mirror, verbal . Rotator Cuff feedback, manual . SlScapular Muscl es . Exercises with more ‘vertical orientation’ . Other shoulder muscles –elevators,– elevators, etc. increase UT activity

Scapular Muscle Rotator Cuff Muscle . Lower trap and Serratus . Exercise to best activate the cuff . INCREASE muscle activity at the right . IR and ER time during ROM . Shoulder elevation –also hi levels of . Lower Trap cuff . LT muscle test, rows, scaptionscaption,, lower rows, ‘down and back’ command . Respect pain levels and muscle . Serratus Anterior ability to determine start point and . Forward punch, scaption,scaption, knee push-push-upup progression plus, supine punch, dynamic hug, push-push- up plus ER and IR Maintain POSTURE & in non-non-painfulpainful ROM. at 0 deg

Begin with arm at the side Pu ll away / tdtowards your abdomen, then slowly release

Scapular Scapular retraction protraction Grasp band with Supine to reduce both hands, elbows UT activity bent to 90o Pinch shoulder blades together

W’s

Active elevation with upper trap Upper quarter relaxation postural exercise Lift your arm without shrugging Sitting or standing Criteria for progression to Phase 2 Able to perform 3 sets of 10 reps with red non-non-latexlatex or Green latex band without substantial pain or fatigue Strengthen rotators before progression to shoulder elevation

Scaption and Flexion

Shoulder ER and IR Quadruped push up plus (camel) with abd (45o to 90o)

Prone shoulder scapular retraction “T” and “Y” Phase 3 (not everyone will get to Phase 3) Progression: Perform Phase 2 (any color band) for 1 week without an increase in symptoms Continue exercises from phase 2 with progression of therabandresistance Forearm prone plank with plus Body blade Lawn mower pull

3 x 30 sec bouts ** Good scapular control! Start at ~ 60 then 90

Treatment Approach – Evidence – Scapular Dysfunction Limited Evidence . Unsure (limited or no evidence): . Motor Control: . Scapular motor control ex focus . Mechanistic evidence indicated scapular motion / kinematics and muscle activity . Scapular taping can improve (Roy JS, Man Ther,Ther, 2009; Worsley P, JSES, 2012; . Core stability training DeMey K, JOSPT, 2012; Baybar, PTJ, 1998) . Eccentrics focus . Pts reported  pain &  function with motor control focus . **Limitation: not RCTs (Roy JS, Man Ther,Ther, 2009; Worsley P, JSES, 2012; StruyfF, Clin RheumatolRheumatol,, 2012)

Scapular Control Evidence – Scapular Dysfunction and Mobility . Scapular Stabilization addition: . Addition of scapular stabilization exercises to the ‘standard’ ex program of stretch and strengthen . Improved muscle LT and elevation HHD strength and scapular dyskinesis

((BaskurtBaskurtZ, J Back MSK Rehab, 2011) Leukotape Scapular Taping Core strength (Hsu, Yin-Yin-HsinHsin,, 2009; Lewis J, JOSPT, 2005; Selkowitz DM, JOSPT, 2007) Assess core strength; Elastic tape can they do the following and maintain upright w/o deviations? – Single leg stance – Single leg squat Effects in pts with SAIS: – Single leg squat with •  thoracic extension arm movement (sport or •  GH & scapular motion work activity) •  UT &  LT ms activity • Immediate effects only for patient-report

NonNon--thrustthrust Manipulation (Mobs) Evidence – Manual Therapy & thrust Manipulations . MT to GH, & or spine + ex vsexercise alone General categories: . Better than ex alone to improve function (Bang M, 2000; Bennell,Bennell, 2010; Winters, 1999) 11--  pain  evidence supports 22--  spine motion  NO evidence  motion, GH mobs + ex or GH mobs alone vs. ex tt--spine,spine, ??? rationale for treatment ??? . . No better outcomes (Chen J, 2009; YiasemidesR, 2011; 33-- Central mechanisms via spinal cord to Kachingwe A, 2008) brain level  neneurophysiologicalurophysiological effects of . Better outcomes ((SenbursaSenbursa,, 2011; Senbursa,Senbursa, 2007; Conroy, manipulation that can improve ms activity, 1998) reduce pain locally and peripherally via . Considering quality of trials and effect sizes… central mechanisms

Thoracic PA Evidence – Manual Therapy glide . Spinal manipulation Seated, pt grasps hands . SingleSingle--armarm –1– 1--22 Rxs of tt--spinespine manip to behind neck upper, middle, lower  improve shoulder Make a ““veevee”” AROM & patientpatient--ratedrated outcome ((StrunceStrunce J, 2009; Mintken P, 2010; Boyles R, 2009) with thumb and . RCT –improved outcomes with thoracic index finger or use pisiform to manipulation & HEP (Bergman, 2004; Winters J, 1999) apply posterior . Spinal manipulation appears to be to anterior glide beneficial. Active ingredient of Manual while extending Therapy package? thoracic spine Thrust prone Thoracic Thrust supine

Spine Exercises/ Mintken et al upper and mid SelfSelf--Mobilizations – Supine over a towel – Supine over a roller – Seated thoracic and cervical extension over chair

GH mob: post glide during elevation Posterior capsule (Mulligan MWM) stretch

Posterior glide Stabilize scapula during arm elevation medially using thenar eminance of one hand Use other hand to apply a medially directed force 30 seconds x 3 GH mob / glides: AC Joint: anterior and inferior glide

Evidence –HEP– HEP Recruit patients with SAIS . Home exercise programs can reduce pain and improve function Ludewig & Clinician History and Examination BorstadBorstad,, OccupEnviron Med, 2003; Walther M JSES, 2004)

. This approach may be appropriate Treatment Using Evidence-Based for some patititents, btbut likliklely not all, Guidelines as all patients did not resolve What predicts Week 6-8 success with rehab? . Consider this approach! Discharge exam (10 visits or sooner if goals met)

3, 6, 12 Month Outcome Measures Funded by the NATA-REF

Predictors of Predictors of “Successful” Outcome “Successful” Outcome 6 wks –68% had a ‘successful’ outcome – Less loss of active IR 50% DASH  &&GROCGROC – ‘moderate better’ Less loss of passive flexion or abduction AgeAge-- younger Stop sports or ex b/c of shoulder pain Shoulder pain reduced 2/10 pts with scapular reposition test Regular exercise 3x/wk Symptoms 00--66 wks vs 12 wks Serratus anterior weakness Shoulder injection Some college education What’s else? Predictors of non-non-successsuccess and longlong--termterm outcomes… stay tuned! No pain at night RCD Management - Summary 6. Manual: Spine OR combined (GH, spine) . Pain,  joint motion, other neurophysiological . Treatment approach effects, ?? biomechanical at spine?? 1. Strengthen /Motor Control – Rotator cuff, . GH ––alonealone --doesn’tdoesn’t appear effective scapular, shoulder 7. Use of impairments prn Motor control alone –unclear of effectiveness . Guiding Treatment 2. Flexibility –post cuff, pec minor, lats, CT . Hi – MMdodera te – Lo irrit a bility spine Dose: Hi reps (dose) 3. Scapular Dysf–S –Scap taping + Motor Control, . addition of scapular stabilization exercises . Evidence 1st, then if not successful 4. Home exercise program consider other interventions 5. Modalities –limited use, only in . Pt expectationsexpectations-- recovery, PT, PT interveninterven.. combination with active treatment . Judge outcomeoutcome--ptpt--reportreport & performance

RCD Management Thank you for your kind attention! Consensus (evidence): Controversy (weak/ no evidence): . PT helps the majority . Guiding treatmenttreatment-- . Exercise –stretch,– stretch, irritability? strengthen, MC, HEP . Hi dose (reps) . Addition of manual . Motor Control therapy to Exercise – . Scapular taping –only– only Combined or spine immediate effects . US – not effective . Other modalities –ice,– ice, . HEP may be enough for acupuncture, etc… some folks . Spine MT – can impair. drive decision-decision-making?making? . Core stability training

Question and Answer Time Rotator Cuff Tendinopathy: Examination 1/28/2013

Rotator Cuff Tendinopathy: Diagnosis Does it matter ? • Guide Intervention – Is “rotator cuff tendinopathy” a Consensus and Controversies in homogeneous group? Rehabilitation of Rotator Cuff Disease: – If not, how do we subgroup? Examination • Inform Prognosis

Phil McClure PhD, PT [email protected] Does the classic pathoanatomic model work for rehabilitation?

Complaint of “Shoulder Symptom” Orthopaedic Section: Shoulder Guideline Group Level 1 Screen History (A), Basic PE (B), Red Flags (C)

Non-shoulder origin of sx Shoulder origin of sx

Level 2 Specific Phys Exam (D) Pathoanatomic (Med Dx) Diagnostic Classification Scheme Rotator Cuff / Glenohumeral Frozen Shoulder • Screening Impingement Instability

• Pathoanatomic Dx (Medical Dx) Level 3 • Rehab Dx (Irritability) Rehab Dx High Irritability (E) Mod Irritability (F) Low Irritability (G)

Rotator Cuff Tendinopathy: Examination Pathoanatomic Dx vs “Rehab” Dx Overview • Pathoanatomic Dx • Rehab Diagnosis • Differential Dx (Pathoanatomic/Medical Dx) (Medical Diagnosis) – – Sx Severity / Impairment Be sure we have a problem that we can treat – Pathoanatomic – Puts us in the “ball park” – “Irritability” – Primary Tissue • Current intensity • Identification of Key Impairments (Rehab Dx) Pathology – Often changes over – Guides specific rehab treatment – Stable over episode of episode of care – Weakness( Motor control, inhibition, disuse atrophy, tears) care – Guides specific rehab Rx – Mobility (tightness or laxity… shoulder girdle & spine) – Guides general Rx – May inform prognosis strategy – Scapular Dysfunction (due to weakness or mobility) – Informs prognosis – Environmental factors leading to overuse – Important for Surgical • Outcome Measures (How do we keep score?) Decisions

McClure 1 Rotator Cuff Tendinopathy: Examination 1/28/2013

Rotator Cuff Tendinopathy: Examination Differential Diagnosis

• Things that may look like RC tendinopathy… but are not – Cervical spine Test --LRLR+ LR • Pain location, ROM, Upper Limb tension test, Spurlings, Traction test ULTTa .12 (neg helps r/out) 1.3 – Thoracic Outlet • Pain location, Upper Limb tension test, palpation brachial plexus @ Involved Cerv Rot .23 (neg helps r/out) 1.8 Erb’s point, Adson’s <60 deg – Frozen shoulder Distraction Test .62 4.4 (pos help r/in) • LOM in multiple planes, females, 40‐60 yo – Nerve injury (suprascapular, axillary, long thoracic) Spurling’s .58 3.5 (pos help r/in) • Hx: traction or direct blow, weakness, palpation 2 of 4 .88 – Red Flags (Cardiac, Pancoast’s tumor) • Pain location, males > 50, smoking 3 of 4 6.1 4 of 4 30.3

Wainner et al, Spine 2003 (NCS/EMG as criterion)

Pain Location Pain Location

AC Jt Subacromial space Subacromial injection of 1.5 ml of 5% hypertonic saline

• Anterolateral shoulder pain

•Pain above acromion rare

• Pain below elbow possible 4/17 •Anterolateral pain in all •Posterior pain 3/10 Hypertonic saline under •No pain above acromion or in flouroscopic guidance supraspinatus muscle / scapular area Gerber, 98, JSES Stackhouse et al. 2012 JSES

Kellgren Clin Sci, 1939 Cloward, 1959 Annals of Surgery Brachial plexus entrapment/TOS Feinstein JBJS, 1954 Discogenic pain Interspinous Ligaments Special tests

• Elevated Arm Stress Test

•ULTT

• Others

Dwyer et al Adson’s Costoclavicular Direct palpation Spine 1990 compression

Facet pain Positive test = reproduce chief complaint sx

Diagnostic accuracy uncertain because gold standard is lacking

McClure 2 Rotator Cuff Tendinopathy: Examination 1/28/2013

Rotator Cuff Tendinopathy: Examination Rotator Cuff Tendinopathy: Examination Differential Diagnosis Differential Diagnosis

• Things that may look like RC tendinopathy… but are not • Things that may mimic or accompany RC tendinopathy – Cervical spine – Reasons why the patient may not respond well • Pain location, ROM, Upper Limb tension test, Spurlings, Traction test • Full thickness RC tear – Thoracic Outlet – Age, weakness w/empty can, ER lag signs, Drop Arm • Pain location, Upper Limb tension test, palpation brachial plexus @ • SLAP lesion Erb’s point, Adson’s – Hx (click, pop, catch) + multiple tests – Frozen shoulder – Biceps load, crank test, dynamic shear, Ant Slide, Speed’s • LOM in multiple planes, females, 40‐60 yo • GH Instability – Nerve injury (suprascapular, axillary, long thoracic) – Hx, Apprehension/Relocation test, Sulcus • Hx: traction or direct blow, weakness, palpation • AC joint – Red Flags (Cardiac, Pancoast’s tumor) – Pain location, palpation, horiz adduction, O’brien’s • Pain location, males > 50, smoking • Myofascial Trigger Points – Palpation of muscle belly

Rotator Cuff Tendinopathy: Examination Rotator Cuff Tendinopathy: Examination Differential Diagnosis Differential Diagnosis

• Things that may mimic or • Things that may mimic accompany RC tendinopathy or accompany RC tendinopathy • Full thickness RC tear • – Age, weakness w/empty can, ER SLAP lesion lag sigg,ns, Drop Arm – Hx (click,pop,catch) + muliltip le tests Kibler 09, JSES – All 3 tests tend to show : – Crank test, Biceps load, – High specificity Speed’s, Anterior Slide, Dynamic shear – Mod sensitivity – Helpful to r/in – Dx Accuracy Variable – – Not as helpful to r/o Specificity: Mod‐High – Sensitivity : Low‐Mod

Rotator Cuff Tendinopathy: Examination Rotator Cuff Tendinopathy: Examination Differential Diagnosis Differential Diagnosis

• Things that may mimic or • Things that may mimic or accompany RC tendinopathy accompany RC tendinopathy • GH Instability • AC joint – Hx, Apprehension/Relocation, Sulcus – Pain location, palpation, horiz adduction, active – Dx Accuracy compression (O’brien) – Specificity : High – (apprehension, not pain) – High Specificity – Sensitivity : Mod – Variable sensitivity – Sulcus?

McClure 3 Rotator Cuff Tendinopathy: Examination 1/28/2013

Rotator Cuff Tendinopathy: Examination Rotator Cuff Tendinopathy: Examination Differential Diagnosis Differential Diagnosis

• Things that may mimic or • Things that may mimic or accompany RC tendinopathy accompany RC tendinopathy – Reasons why the patient may not respond well • Full thickness RC tear • Myofascial Trigger Points – Age, weakness w/empty can, ER lag signs, Drop Arm – Palpation of muscle belly • SLAP lesion – Hx (click, pop, catch) + multiple tests – Repro CC pain, taut band – Biceps load, crank test, dynamic shear, Ant Slide, Speed’s • GH Instability – Hx, Apprehension/Relocation test, Sulcus • AC joint – Pain location, palpation, horiz adduction • Myofascial Trigger Points – Palpation of muscle belly

??? Do these negatively affect prognosis?

Rotator Cuff Tendinopathy: Examination BJSM 2012 Differential Diagnosis • Rotator Cuff Tendinopathy – aka subacromial impingement …more than you ever wanted to know – Neer’s – Hawkin’s about diagnostic accuracy! – Jobe’s Empty can (isom resist elev w/IR in plane of scap) – Painful Arc (60‐120 deg) – Isom resist ext rot (Infraspinatus test) – Speed’s – Horizontal adduction – palpation

Diagnostic Accuracy of Clinical Tests for the Different Degrees Diagnostic Accuracy of Clinical Tests for the Different Degrees of of Subacromial Impingement Syndrome Subacromial Impingement Syndrome Park et al, JBJS, 2005 Park et al, JBJS, 2005 • Large Series, n= 359 • Physical Exam findings compared with Diagnostic Arthroscopy • High Sensitivity • High Specificity • 8 tests • Negative test helps rule out • Positive test helps rule in – Neer’s – Hawkin’s – Neer’s – Speed’s test – Hki’Hawkin’s – Cross‐bdbody Adduc tion – Painful Arc Pain – Speed’s test – Painful Arc – Drop Arm test – Cross‐body Adduction – Supraspinatus (empty‐can – Drop Arm test position) – Supraspinatus (empty‐can position) Best Overall Combination – Infraspinatus (Arm at side) Weakness •Hawkin’s – Infraspinatus (Arm at side) •Painful Arc •Infraspinatus test

McClure 4 Rotator Cuff Tendinopathy: Examination 1/28/2013

Diagnosis of Rotator Cuff Tendinopathy (aka subacromial impingement) My bottom lines: N=55, Surgical Dx was gold standard • Always some degree of uncertainty 16/55 confirmed impingement, 39/55 negative

+ LR ‐ LR • Correlate with hx and sx’s Neer 1.8 0.35 • Look for multiple tests to be positive/negative Hawkins 1.6 0.61 Painful Arc 2.3 0.36 • Try to identify other coexisting pathology Empty can 3.9 0.57 – Do these affect outcome? (weakness) Ext Rot Resist 4.4 0.5 (weakness) >3/5 positive 2.9 ‐ • Pathoanatomic diagnosis may not be critical < 3/5 positive 0.34 to directing rehab treatment

Rotator Cuff Tendinopathy: Examination Complaint of “Shoulder Symptom” Differential Diagnosis Level 1 Screen History (A), Basic PE (B), Red Flags (C)

Summary: Pathoanatomic/Medical Non-shoulder origin of sx Shoulder origin of sx Dx • Rule Out Other Diagnoses Level 2 Specific Phys Exam (D) – C‐spine / TOS / FrozenShdr / Nerve Injury / Red Flag Pathoanatomic • Identify Additional problems (Med Dx) Rotator Cuff / Glenohumeral Frozen Shoulder – RC Tear / SLAP / Instability / AC Jt / Trigger Pts Impingement Instability • Rule In RC tendinopathy – (+) Neer or Hawkins Level 3 Rehab Dx – (+) Pain/weakness with resisted Empty can or Ext Rot – Painful arc High Irritability (E) Mod Irritability (F) Low Irritability (G)

Rotator Cuff Tendinopathy: Examination Rotator Cuff Tendinopathy: Examination “Rehab Diagnosis” Irritability Classification • Identify Stage of Irritability Irritability • Identify specific impairments that guide treatment High Moderate Low History • High Pain (> 7/10) • Mod Pain (4-6/10) •Low Pain (< 3/10) – Weakness (Cuff ) and • night or rest pain • night or rest pain • night or rest pain Exam • consistent • intermittent • none – Tightness (post capsule, pec minor, lats, t‐spine) • Pain before end ROM • Pain at end ROM • Min pain •AROM < PROM •AROM ~ PROM w/overpressure • High Disability • Mod Disability •AROM = PROM – Scapular Dysfunction •(DASH, ASES) •(DASH, ASES) • Low Disability •(DASH, ASES)

Treatment • pain reduction • pain reduction • High demand Focus • activity modification • impairments functional activity • basic function restoration

Kelley et al JOSPT 09

McClure 5 Rotator Cuff Tendinopathy: Examination 1/28/2013

Matched Treatment Strategy Rotator Cuff Tendinopathy: Examination High Irritability Moderate Low Irritability Specific Impairments: Cuff Weakness Irritability Patient Education +++ • Cuff “weakness” (? inhibition) Activity Modification + + / -- -- allows superior migration which may perpetuate impingement ROM/ Stretch Pain-free passive AAROM  End-range/ AAROM AROM overpressure Manual Techniques Low grade Low / High grade High grade

Neuromuscular -- Light  mod Mod  high resistance Performance resistance End-ranges Mid-ranges Functional Activities -- Basic High demand

Modalities +/‐ +/‐‐‐ Taping / functional + / -- + / -- + / -- support (brace / external)

Mechanisms of Impingement “Gaps” related to muscle performance Muscle Performance • Does an isometric test of peak force • Several studies have documented abnormal adequately capture “muscle performance”? superior glide under different conditions: – Motor control during dynamic activity? • Cuff tear: – Deltoid/cuff balance? – 100% with full RC tear – 14% after cuff repair – Endurance ? – Paletta JSES ’97 – What is the source of weakness? • Cuff tear or Stage II • Poor motor control => quality vs quantity in exercise impingement – Deutsch JSES ’96 • Poor neural activation from CNS => estim, biofeedback or better • Muscle fatigue pain control to avoid inhibition – Chen JSES ‘99 • Disuse atrophy => traditional PRE • Tear => surgery or compensatory strategy

Rotator Cuff Tendinopathy: Examination Posterior Shoulder Tightness: Specific Impairments: Posterior Tightness What do we measure?

• Posterior Capsule (Harryman, 1990)

increased posterior shoulder tightness

HH sup translation & ed GH IR AROM Awan et al APMR, 2002 decreased subacromial space Decreased IR ROM on side of Tyler et al; JOSPT, 1999 mechanical compression of SA tissues impingement compared to unaffected side Tyler et al, 2000 AJSM Glenohumeral Mallon et al JSES, 1996 Internal An increase in IR ROM correlated well (r=0.54) with improved Edwards et al JSES 2002 Rotation outcome following rehab at 6wks Deficit McClure 04, PTJ ASES: Richards et al JSES 94

McClure 6 Rotator Cuff Tendinopathy: Examination 1/28/2013

PROM: Internal Rotation 90° abduction Total Arc of • Supine Rotational Motion • Humerus 90° abduction, elbow flexed 90° Throwers • Fulcrum at olecranon - Increased ER process - Decreased IR - may be attributable to bony changes in • Stationary arm From Wilk 09 JOSPT glenoid or humeral retroversion perpendicular to floor • Align moveable arm with ulnar styloid • End the movement when the acromion elevates anteriorly (beyond dashed line in top picture)

PROM: Horizontal adduction Accessory Motion: GH and AC jts ICC= 0.79 • Pain MDC90=8 deg • End‐Feel r= 0.54 w/IR90 • Motion • Reliability?

ICC= 0.94

MDC90=4.2 deg

r= 0.35 w/IR90

Salamh, IJSPT, 2012 Myers, AJSM 2007

Rotator Cuff Tendinopathy: Examination Rotator Cuff Tendinopathy: Examination Specific Impairments: Tightness (Latissimus) Specific Impairments: Posture, Thoracic Spine, Pec minor Tightness (Kendall and McCreary, 1993, Cleland et al, 2007) • Posture • Reduced latissimus A – Thoracic kyphosis and protracted shoulder may decrease subacromial length indicated by space and put rot cuff at mechanical obviously decreased disadvantage Lewis 07 BMC Musc • Kebeatse 99 APMR, Solemn‐Bertoft 93 CORR – No good evidence suggesting flexion in B Kluemper 06, J Sp Rehab posture is strongly related to sx’s compared to A • Pec Minor tightness B – may alter scapular kinematics – Less post tilt, less scap ext rot • Borstadt 05 JOSPT Borstad 05 JOSPT Tate 12 JAT – Shorter in symptomatic HS swimmers (Tate 2012, JAT) – No good evidence suggesting pec minor is strongly related to sx’s

McClure 7 Rotator Cuff Tendinopathy: Examination 1/28/2013

Rotator Cuff Tendinopathy: Examination Rotator Cuff Tendinopathy: Examination Specific Impairments: Tightness (Thoracic mobility) Specific Impairments: Scapular Dysfunction

• Spring testing – Based on examiners perception • Visual Classification of mobility at a level relative to – Scapula Dyskinesis Test (McClure 09 J Athl Tr) those above and below and examiner’s experience and • Symptom Altering Tests perception of normal – Scapula Reposition Test (Tate 08, JOSPT) – Hypomobile/Hypermobile – ? Pain – Scapula Assistance Test (Rabin 06, JOSPT) • Biomechanic vs Neurophysiologic • Force Measures Mechanisms • If not stiff, do we still manipulate? – Trap – Serratus

Scapular Dysfunction Scapular Examination: • Is it related to common Specific Impairments shoulder pathologies? • Is there “Dysfunction”? – Maybe • Visual Classification – Most studies show small (but • Scapula Dyskinesis Test (McClure 09 JAT, Tate 09, JAT) stat sig) motion differences • “Yes /No” test (Uhl , 09, Arthros) between groups (sx vs asymp) • Symptom Altering Tests – Large variability in “normal” or • Scapula Retract/Reposition Test (Kibler 06 AJSM, Tate 08, JOSPT) asymptomatic subjects • Scapula Assistance Test (Rabin 06, JOSPT) – Strong evidence showing scap • If there is Dysfunction…Why? dysfunction causing shoulder • Muscle Strength / Motor Control pain / pathology is lacking • Trap • Serratus – Must try to relate sx’s to scap • Flexibility of Key Structures: Pec Minor, T‐spine, Post Cap dysfunction in specific patient

Classifying scapular motion: the scapula dyskinesis test (SDT) Dyskinesis: Winging • Movement of medial border • 5 repetitions:: – Flexion (weighted) and/or inferior angle away – Abduction (weighted) from the thorax, becoming • Rate scapular motion on each test as: – Normal (N) motion: no evidence of more prominent during arm abnormality • Medial border and inferior angle relatively motion with a sulcus/gap flat between the scapula and the – Subtle (S) dyskinesis: mild/questionable Picture: Posterior view of winging evidence of abnormality, not consistently thorax: present – Obvious (O) dyskinesis: striking, clearly . ≥1” is considered abnormal apparent abnormalities, evident on at least 3/5 trials . May be unilateral or • Winging 1” or greater displacement of bilateral scapula from thorax • Dysrhythmia • Subjects may repeat test

Picture: Superior view of winging

McClure 8 Rotator Cuff Tendinopathy: Examination 1/28/2013

Dyskinesis: Dysrhythmia Winging Describes a lack of “smooth” scapulohumeral rhythm – A “hitch or a jump in the otherwise smooth motion.” (Kibler, 2003) – Most common pattern is

early/excessive scapular Picture: Example of “shrug” during arm raising elevation (shrug) Dysrhythmia: – Another common pattern: “Dumping” rapid downward rotation during lowering (dump)

Picture:“Dumping” during arm lowering

Are Symptoms Related to Dyskinesis? Arthros 09

• Penn Shoulder Score (Leggin et al 06) Pain > 3/30 -Sx's + Sx's – Pain Sub‐Scale - Dyskinesia 39 37 • Total 30 Compared asymmetry in 3D testing + Dyskinesia 16 12 – Sx’s at rest (0‐10) -sx’s (n=35) vs no sx’s (n=21) – Sx’s with normal use (0‐10) OR = 0.79 (0.33 -1.89)-1.89) - Flexion probably most sensitive – Sx’ s with strenuous use(0‐10) - Asymmetry common • n = 104 – Only subjects rated as obvious or normal by two raters – Rater disagree or subtle discarded Pain > 6/30 -Sx's + Sx's • Odds ratios (95% CI) - Dyskinesia 61 15 Type 1 Type 2 – Does having dyskinesis + Dyskinesia 24 4 increase your odds of OR = 0.68 (0.2 -2.25)-2.25) having sx’s? … NO

Type 3 Type 4 (normal/sym)

Symptom Altering Tests Measuring Shoulder Outcome: Keeping Score! • Modified Scapular Assistance Test – Posteriorly tilt and upwardly rotate scapula (Rabin et al, JOSPT 2006) – Documented reliability (77‐91% agreement) – 40‐49% tested “positive” (> 2pt change) • Scapula Retraction Test – Kibler et al AJSM, 2006 – Patients and healthy – increased strength with scap stabilization – No sig change in pain • Scapula Reposition Test – Tate, McClure, Kareha, Irwin (JOSPT 2008) – Overhead athletes, Empty can test – 26‐29% had significant increase in strength – 48% had decrease in pain

McClure 9 Rotator Cuff Tendinopathy: Examination 1/28/2013

Shoulder Pain Shoulder Outcome Scales

Michener et al, JSR, 2010 Mintken et al JSES 2009 • DASH (Disabilities of the Arm, Shoulder, Hand) • Ave of 3 Pain items • Ave of 3 Pain items • Quick DASH • NPRS 0‐10 • NPRS 0‐10 • ASES (American Shoulder and Elbow Surgeons) – Rest – Current • PENN Shoulder Scale – Normal ADL – Least 24 hr – Strenuous – Worst 24 hr • Lots of others! – 4‐6 wk Rx – 2‐4 wk Rx • MCID: 2.2 • MCID 1.1 • MDC 2.5 Bottom Line: Look for at least a 2 pt change in pain

DASH/Quick DASH Shoulder Outcome Scales Sports/Performing Arts Module Scale Content MDC MCID

DASH 30 questions 12.8 10.2 sx’s (5), & function (25) 0-100 scale Quick 11 questions 11. 2 808.0 sx’s (3)& function (8) DASH 0-100 scale

ASES 10 function (50%) 9.7 6.4 Pain (50%) 0-100 scale Penn SS 30 Pain 12.1 11.4 10 Satisfaction 60 function 100 Total

Rotator Cuff Tendinopathy: Examination Evaluate/Manage Patient Expectations Summary • Differential Dx (Medical Dx) Questions – C‐spine, TOS, Frozen Shdr, Nerve Injury, RedFlags • Do you expect to get better? – RC Tear, labral injuries, GH instab, AC jt, Trigger pts • Do you think PT will be helpful? • Rehab Dx • Any specific treatment you think will be most effective? – Irritiability (guides Rx strategy and intensity) – Key Impairments • Use to evaluate and influence • “Weakness” (cuff & scapula) patient expectations. • Tightness (post capsule, pec minor, lats, cervicothoracic ) • Scapular Dysfunction (motion and sx altering tests) • Outcome Measures (keeping score) – DASH, Quick DASH, ASES, Penn Scale, others

McClure 10 Rotator Cuff Tendinopathy: Examination 1/28/2013

Rotator Cuff: Examination

Consensus (evidence): Controversy (weak/no evidence) • r/o other pathology • Does co‐existing pathology • Key Sx’s predict worse outcome or require – Ant/lat arm pain different treatment? • – Often overuse What impairments are truly related to sx’s ? (causal or • Key Signs perpetuate) – Multiple should be present – Scapular Dysfunction • Key Impairments: • Motor control / weakness – Cuff “weakness” • Tightness • Source? Endurance? – Pec tightness (clinical measure?) – Posterior tightness – Thoracic mobility • Use an Outcome scale

McClure 11