New Significant Shoulder Diagnostic Test

By Warren Hammer, MS, DC, DABCO

One of the challenges we have with shoulder pain is determining if the cause of the pain is an impingement syndrome; the next challenge is to determine if a soft tissue treatment will be beneficial. 
A soft tissue treatment will be beneficial if the site of impingement is subacromial, rather than intra-articular.

There are a variety of tests for determining impingement: the Neer and Hawkins tests,¹ and other indicators from a shoulder examination. But a major question is determining if the impingement pressure is occurring in the subacromial area, that is: a thickened and inflamed subacromial bursa; erosions on the coracoacromial ligament and undersurface of the acromion; and bursal-side partial or full-thickness tearing of the rotator cuff. Or is the impingement pressure more intra-articular: internal posterosuperior glenoid impingement; microinstability causing a secondary impingement; middle glenohumeral ligament tearing; labial tears; anterior glenoid erosions; SLAP (superior labial lesion); chondral lesions; or failure of the humeral head to normally translate posteriorly with maximum external rotation.

There are tests to help determine intra-articular possibilities,² but a major reason for differentiating subacromial from intra-articular (from a soft-tissue treatment point of view) is that soft tissue treatment is not very effective for intra-articular lesions.

Zaslav³ developed an internal rotation resistance strength test to differentiate between outlet (subacromial) and nonoutlet (intra-articular) causes of shoulder pain in patients with a positive impingement sign. The test was found to have an 88 percent positive predictive value; a 96 percent negative predictive value; an 88 percent sensitivity; a 96 percent specificity; and a 94.5 percent accuracy.

The internal rotation resistance strength test (IRRST) is performed by the examiner standing behind the patient. The patient's arm is in 90° of abduction in the coronal plane, with the forearm in 80û of external rotation (Figure 1). In this position the forearm is isometrically resisted for external rotation, and then compared with internal rotation isometric testing²(Figure 2). The IRRST is considered positive if, along with a previous positive impingement test, there is good strength in external rotation and apparent weakness in internal rotation. "Because this is a test of relative weakness in a pathologic shoulder, strength is not compared with the opposite side."2 A positive test indicates an intra-articular, nonoutlet impingement, while a negative test (more weakness and probable pain in external rotation) indicates a subacromial outlet impingement.

Figure 1: Resisted external rotation at 80° to 85° in the coronal plane.

Figure 2: Resisted internal rotation at 80° to 85° in the coronal plane.

The biomechanical theory for the positive test of an "apparent" rather than a "true" weakness in internal rotation is as follows: with resistance of internal rotation in the 80° to 85° external rotation position, a vector is created that pushes the humeral head anteriorly toward the anterior glenoid rim and labrum. Tension also occurs along the biceps labial complex and the capsulolabral border "so that pain from both subtle subluxation and biceps and SLAP lesions will be magnified in this position, causing the appearance of weakness."² This internal resistance position results in a forward movement of the humeral head, thereby reducing the normal obligate posterior translation that occurs with external rotation. This causes the rotator cuff to be contacted between the superior glenoid and humeral head, which produces pain. The authors feel that this test is especially helpful in the more subtle forms of internal and secondary impingement related to instability in the younger patient. In the 50-year and older population, there was more weakness in external rotation (94 percent); the younger-than-50 population exhibited more weakness in internal rotation (66 percent of the time.) This test agrees with present-day research indicating that younger patients suffer with more instability than older patients in the shoulder area.

I have found this test to be very useful in differentiating the location of the impingement lesion.

References 

1. Hammer WI. The latest information on the Neer and Hawkins impingement signs, DC, Oct. 16, 2000 (www.chiroweb.com/archives/18/22/06.html).
2. Hammer WI. Functional Soft Tissue Examination & Treatment by Manual Methods: New Perspectives, 2nd edition. Gaithersburg, MD, Aspen, 1999.
3. Zaslav KR. Internal rotation resistance strength test: A new diagnostic test to differentiate intra-articular pathology from outlet (Neer) mpingement syndrome in the shoulder. J Shoulder Elbow Surg, Jan/Feb 2001.

Warren Hammer,MS,DC,DABCO
Norwalk, Connecticut 

Exercising the Rotator Cuff - Minus the Deltoid

By Warren Hammer, MS, DC, DABCO

The rotator cuff acts in concert with the deltoid to elevate the shoulder. An important function of the cuff muscles is to keep the head of the humerus centered within the glenoid cavity (concavity compression), and at the same time, to impose an inferiorly directed force vector to the humeral head. 
The chief compressor is the supraspinatus, while the teres minor, infraspinatus and subscapularis also act as compressors, but also provide an inferior force to keep the humeral head from shearing upward during arm elevation. This function is crucial; if the humeral head is not maintained adequately within the glenoid, normal deltoid contraction will cause a superior translation and an upward shearing of the head to the acromion and coracoacromial ligament above.

Frequently, rotator cuff lesions are caused by intrasubstance degenerative tearing, or tendinosis due to avascularity, aging or overuse. Other potential causes include trauma, outlet stenosis or glenohumeral instability.¹These types of lesions result in weakness of the cuff muscles - especially the supraspinatus, which lose their ability to oppose the superior migration of the humeral head with active elevation of the arm. This superior migration functionally narrows the subacromial space; eventually, the greater tuberosity and the rotator cuff abut against the under-surface of the acromion and the coracoacromial ligament, leading to what is known as "secondary impingement." The articular side of the supraspinatus and the anterior infraspinatus insertion also is at risk, because it has a poorer blood supply than the bursal side.² "Primary impingement" is an extrinsic force directed to the superior portion or bursal side of the cuff, and is not nearly as common as secondary impingement.

Morrison³ stated that the basis of rotator-cuff disorders is a muscle imbalance between the elevators and depressors of the humeral head (the deltoid and the rotator cuff). He further stated that as a natural part of aging, the deltoid retains its strength longer than the relatively diminutive rotator cuff, resulting in a loss of the depressor effect of the rotator cuff on the humeral head during elevation, leading to subsequent impingement. Even normal shoulders, when overloaded and fatigued, as in swimmers; players of racquet or throwing sports; or those with occupational demands, have been found to fatigue the cuff muscles, resulting in superior migration of the humeral head. This migration results in lesions on the underside (articular) portion of the cuff, and also may be responsible for lesions on the bursal side of the cuff.

Burkhead² found that the type-3 acromion, which has a hook that impinges on the bursal side of the cuff, often is not an abnormal acromion, but a traction spur of the coracoacroial ligament caused by the repetitive superior migration of the humeral head overloading the ligament. The coracoa cromial ligament functions as a stabilizer against the superior migration of the humeral head.

All of the above evidence demonstrates that weakness of the cuff should be avoided, especially in the early stages of a tendinosis-type problem, and that exercises should be prescribed that strengthen the cuff muscles with minimal or no contraction of the deltoid muscle. Kibler⁴recommended closed-chain exercises, in which the distal part of the segment is fixed and movement occurs at the proximal segment, for example, the knee is exercised with the foot on the ground. In an open chain, the distal segment moves in space. With a closed-chain shoulder exercise (See Figures 1 and 2) performed in the scapular plane (with the arm about 30 degrees anterior to the coronal plane), there is proper scapular position and stability, allowing the rotator cuff to work as a "compressor cuff," conferring concavity compression and a stable instant center of rotation.

A benefit of closed-chain activity (especially at 90 degrees, the level of most throwing activities) is that the normal proprioceptive pathways that exist in the throwing motion are simulated, allowing feedback from the muscle spindles and Golgi tendon organs, in their proper anatomic positions. Closed-chain activity also replicates the normal ball and socket kinematics, minimizing translation in the mid-ranges of motion. Deltoid activation is decreased significantly, lessening the tendency for superior humeral migration if the rotator cuff is weak.³ Open-chain exercises require deltoid action, which creates shear forces at the glenohumeral joint. Deltoid activity will inhibit cuff activity further. Open-chain exercises should be initiated in the latter phases of the rehabilitation program. Early on, if the patient is unable to reach 90 degrees of abduction without pain, the closed chain may be started at 45 degrees of abduction and proceed to 90 degrees as tolerated.

Figures 1 and 2 (page 30) show a patient pushing against the wall with the shoulder in the scapular plane with the hands starting at "8 o'clock," and progressing to "4 o'clock." Pressure is exerted against the wall at 10-second intervals, moving up to the 4 o'clock position. This allows for rotation of the humerus with the arm at 90 degrees of abduction, which replicates rotator cuff activity from extreme internal to extreme external rotation, activating all of the cuff muscles. Before activating the cuff muscles, you can activate the scapular stabilizers by instructing the patient to place his or her arm and hand at the 12 o'clock position (with the arm in the same closed-chain position) and retract, protract, elevate and depress the scapula.

References

1. Budoff J, Nirschl R, Guidi E. Debridement of partial-thickness tears of the rotator cuff without acromioplasty. J Bone and Joint Surg 1998;80A(5)1998.
2. Rothman RH, Parke WW. The vascular anatomy of the rotator cuff. Clin. Orthop1965;41;176-186.
3. Burkhead W, Morrison DS, et al. Symposium: the rotator cuff: debridement versus repair-part II. Contem Orthop 1995;31;313-326. In: Budoff J, Nirschl R, Guidi E. Debridement of partial-thickness tears of the rotator cuff without acromioplasty. J Bone and Joint Surg1998;80A(5).
4. Kibler BW. Shoulder rehabilitation: principles and practice. Med and Sci Sports Exerc1999;30;S40-S50.

Warren Hammer, MS, DC, DABCO
Norwalk, Connecticut
softissu@optonline.net 

Considerations for Conservative Treatment of Rotator Cuff Rupture

By Warren Hammer, MS, DC, DABCO

Conservative care from a manual point of view for cuff ruptures has to do with friction massage, fascial release and rehabilitation i.e., especially strengthening of the cuff muscles. Surgically it has been found that even a massive cuff tear can be treated without repairing the tendon, especially in patients in their 50s and 60s.¹

Studies show² that when tears are repaired greater than 5cm in diameter, the average final postoperative elevation was only 98^o, and when the tears measured 3-5cm in diameter, the average active elevation was 142^o.

Using arthroscopic surgery, consisting of decompression and debridement of the cuff lesion without tendon repair, seems in many cases to be more beneficial for the 50 and older patient. Debridement is the removal of foreign material, devitalized or contaminated tissue, leaving the normal tissue. A rupture, especially less than 2cm, responds to procedures that do not attempt to repair the tendon tear,³ although large tears (up to 5cm) have also responded. Hawkins4 followed the nonoperative management of full-thickness cuff tears for 7.6 years and found that function did not deteriorate with time.

The authors concluded³ that the shoulder pain and loss of function was due to a thickened inflamed subacromial bursa impinged beneath the cora-coacromial arch, rather than the actual tear. This knowledge of scarred bursal tissue rather than the tear itself aggravating the patient, may explain the beneficial results of friction massage and fascial release for cuff tears. We know that friction of soft tissue causes an increase in fibroblastic proliferation and fibroblasts synthesize and maintain collagen, fibronectin, proteoglycans and other proteins of the connective tissue matrix. The fibroblasts continually replace and remodel the matrix.⁵ In other words, deep friction can repair the thickened inflamed bursa, as it has done for chronic bursitis of the shoulder and hip.⁶

It has been found that rotator cuff tears are especially common in patients 50 and up with rather good shoulder function. Basmajian and MacConaill7 proved that the supraspinatus muscle was not necessary for normal shoulder motion. Complete paralysis of the supraspinatus only reduced the force of abduction. As long as the cuff depressors of the humeral head (infraspinatus, teres minor and subscapularis) are intact, there will be adequate glenohumeral concavity compression, allowing the deltoid to elevate the arm. While the deltoid/rotator cuff force couple (coronal plane) is important, another force couple between the subscapularis and the combined infraspinatus and teres minor is also important. This is the force couple that works in the transverse plane i.e., the anterior (subscapularis) and posterior portions (infraspinatus/teres minor) of the rotator cuff.

In most cases, large rotator cuff tears extend posteriorly rather than anteriorly, therefore involving mostly the infraspinatus muscle/tendon. Testing of the infraspinatus will be extremely weak, usually along with the supraspinatus. Tearing of the infraspinatus affects both the coronal and transverse force couples, allowing deficient motion due to loss of the glenohumeral fulcrum. As long as enough of the force couples remain intact and maintain the glenohumeral fulcrum, so that elevation of the humerus is possible, it becomes evident that "the location of the tear seems to be more important than the size of the tear."¹

I have found in many cases of ruptured tendons that deep friction massage to the subacromial bursa and areas in and around the cuff muscles helps to decrease pain and restore function. Especially in older patients suffering with pain and weakness due to tendon rupture, reducing the inflamed scarred bursae by increasing fibroblastic proliferation (friction massage) and muscle strengthening, is definitely a worthwhile procedure for several months before resorting to surgery.

References

1. Burkhart SS. Arthroscopic treatment of massive rotator cuff tears. Clin Orth & Rel Res 267, 1991.
2. Cofield RH. Results of rotator cuff repair. Symposium on disorders of the Shoulder. Modern Orthopaedic Management. Houston, Texas, Apr. 29-30, 1988.
3. Hoe-Hansen CE, Palm L, Norlin R. The influence of cuff pathology on shoulder function after arthroscopic subacromial decompression: a 3 and 6-year follow-up study. J Shoulder Elbow Surg 8(6), 1999.
4. Hawkins RJ, Bokor DJ, Angelo RL. Full thickness rotator cuff tears: a long-term follow-up of nonoperative management. 5th Open Meeting of the American Shoulder and Elbow surgeons, Las Vegas, Nevada, Feb 12, 1985.
5. Hammer W. Functional Soft Tissue Examination and Treatment by Manual Methods: New Perspectives, 2nd. ed. Gaithersburg, MD, Aspen. 1999.
6. Hammer W. The use of transverse friction massage in the management of chronic bursitis of the hip or shoulder. JMPT 1993, 16(2):107-11.
7. MacConaill MA, Basmajian JV. Muscles and Movements. Baltimore, MD, Williams & Wilkins, 1969:195.

Rotator Cuff Syndrome

Management of Rotator Cuff Syndrome

By R. Vincent Davis, DC, PT, DNBPM

The rotator cuff of the shoulder is a musculotendinous cuff which is composed of muscular fibers of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles. These muscular fibers blend with and reinforce the capsule of the shoulder joint. 
The etiology of this form of omodynia involves a tear in the fibers of one, or more, of these muscles and presents clinically with shoulder pain which is aggravated by motion and results in impairment of normal range of motion. Since a minor stress can easily cause a partial or complete tear of tissue already impaired by degenerative changes, these clinicopathologies are relatively common. Ischemically induced changes in such degenerative lesions predispose these tissues to stress tears due to their friability.

Typically, the history presents with an acute, severe pain of a "tearing" type with a 6 to 12 hour pain-free interval followed by the gradual return of pain and increasing intensity. If the examination reveals the presence of arm abduction, the tear is probably incomplete. In the absence of arm abductability, or the presence of the "drop arm test," the tear is probably complete and the patient should be referred for orthopedic surgical consult.

Treatment regimens for rotator cuff syndrome are controversial. Each physician, regardless of discipline, is influenced and guided by the training and education received relative to treating such pathologies. The following is recommended by this author.

Initially, cryotherapy should be administered following any episode of trauma admitted by the patient as heat therapy superimposed upon acute trauma is contraindicated. The shoulder should be placed in a sling but not fixed to the chest cage. This will provide reduced motion, but avoid immobilization which may predispose to adhesive capsulitis (frozen shoulder).

Following about 72 hours of cryotherapy involving 20 minute exposures to moist cryotherapy, begin pulsed phonophoresis (as often as time and circumstance will permit) with 2.5 percent lidocaine ointment combined with the oil coupling agent directing the sound beam directly over the site of the lesion, and if palpable, over the general area of the "tuft" of the tear. If trauma history is absent in this episode, cryotherapy is disregarded and pulsed lidocaine phonophoresis is commenced including the shoulder sling. Phonophoresis should be set for low intensity, 0.75 W/cm2 maximum, for 8 to 10 minutes, and may be necessary at least once daily for several days until pain allows for beginning of active abduction exercises with the arm in the sling. This procedure is continued so long as pain is present when performing the active abduction exercise.

With the absence of pain during active abduction, the sling is removed and the patient is instructed to begin "walking the wall" with his fingers. If pain reappears with the introduction of this exercise, interferential current therapy is commenced using the Davis procedure. Since pain is a product of stretching shortened soft tissue components, it is to be expected.

All exercises are performed with care initially and then gradually increased in strength and intensity as physiologically tolerated.

The Davis procedure my be performed several times daily, if necessary. The object of the exercises is to come as close as possible to pain-free circumduction of the shoulder joint.

In the absence of any traumatic episode in the history, treatment may include the application of shorthwave diathermy. This author recommends its use prior to performing pulsed lidocaine phonophoresis and should be limited to no more than 20 minutes at each therapy using the triple drum electrode. The purpose of this deep heating agent is to enhance hyperemia in periarticular tissue, thereby attempting to alter the effect of ischemic soft tissue degeneration.

References

Cailliet, R. Shoulder Pain. F.A. Davis 1987.

Davis, R.V. Therapeutic Modalities for the Clinical Health Sciences, 1st ed., 1983. Copyright -- Library of Congress TXU-389-661.

Griffen, J.E.; Karselis, T.C. Physical Agents for Physical Therapists, 2nd ed. Springfield: Charles C. Thomas 1982.

Hoppenfeld Physical Examination of the Spine and Extremities. Appleton, Century, Crofts 1987.

Krusen; Kottke; Ellwood. Handbook of Physical Medicine & Rehabilitation, 2nd ed. Philadelphia: W.B. Saunders Company 1971.

Schriber, W.A. A Manual of Electrotherapy, 4th ed. Philadelphia: Lea & Feibiger 1975.

R. Vincent Davis, D.C., B.S.P.T., D.N.B.P.M.E.
Independence, Missouri

Rotator Cuff Tears

Palpation Test for Diagnosis of Rotator Cuff Tears

By Warren Hammer, MS, DC, DABCO

Wolf and Agrawal¹ used "trans-deltoid palpation" to diagnose full thickness rotator cuff tears and compared their palpation prospectively for 109 consecutive patients who underwent shoulder arthroscopy.
They performed a retrospective analysis on the data to assess the accuracy of the palpation method. The overall diagnostic accuracy of this palpation method was 96.3 percent. The authors used the method of palpation originally described by Codman.²The test is described as follows: 

1. The patient stands with the involved arm relaxed and dangling at the side.


2. The examiner stands behind the patient and holds the patient's proximal forearm with the patient's elbow flexed 90 degrees.


3. The shoulder is brought back into full extension, which allows greater palpation of the humeral head and tendons inserting into the greater tuberosity.


4. The other hand is placed in front of the anterior acromion in the space before the greater tuberosity. For practitioners familiar with my soft tissue course, this is the best position to palpate and treat the supraspinatus tendon as it inserts into the greater tuberosity.


5. While palpating this area with the shoulder in the fully relaxed extension position, the patient's forearm is moved to create internal and external shoulder rotation. Moving the shoulder in internal and external rotation allows the practitioner to palpate the other cuff tendons, i.e., subscapularis and infraspinatus.


6. In a full rotator cuff tear, the eminence of the greater tuberosity will feel quite prominent, and the torn area will feel like a "sulcus," "rent" or soft-tissue defect that has avulsed from the tuberosity. Palpating the anterior and posterior margins of the cuff tear may elicit an avulsed edge. According to Wolf, et al. "Failure to palpate an avulsed edge is indicative of significant retraction."¹


7. Compare with the opposite normal side.

The authors¹ state that in a partially torn or atrophic cuff, an eminence may be palpated, but the "rent" or sulcus is less prominent. When a calcific deposit is present, there is tenderness, but no sulcus. Small, nonretracted full thickness defects in the cuff and partial tears are more difficult to detect with this palpatory test. Tears on the bursal side of the tendon are the easiest to palpate. If patients have a thick adipose layer surrounding the acromion, it may be difficult to palpate the defect.

With the shoulder abducted by the practitioner, to 90 degrees if there is crepitus while the shoulder is rotated internally and externally, this is considered a sign of supraspinatus tearing in both partial-thickness and full-thickness tears. The crepitation on rotation is due to the abrasion of the torn tendon margins against the coracoacromial arch (abrasion sign).³

The drop-arm and lag-sign tests might indicate a rupture. A partial rupture will be more painful than a full-thickness rupture in which the nerves are completely separated.

References

1. Wolf EM, Agrawal V. Transdeltoid palpation (the rent test) in the diagnosis of rotator cuff tears. J Shoulder Elbow Surg 2002;10(5).
2. Codman EA. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or About the Subacromial Bursa, chapter V. Original edition. Boston: Thomas Todd; 1934. p. 123-77. Reprint edition. Melbourne (FL): Krieger; 1984.
3. Matsen FA, Lippitt SB, Sidles JA, Harryman DT. Practical evaluation and management of the shoulder. Philadelphia: W.B. Saunders: 1994, in Hammer WI. Functional Soft Tissue Examination & Treatment by Manual Methods: New Perspectives, 2nd edition, Aspen publishers, Gaithersburg, MD.

Warren Hammer,MS,DC,DABCO
Norwalk, Connecticut 

SLAP Lesion/TEST

An Excellent Test for a SLAP Lesion

By Warren Hammer, MS, DC, DABCO

Has a patient ever complained of nonspecific posterior shoulder pain (usually in the overhead position)? There also may be a painful popping and a sense of looseness in the shoulder, and some positive impingement signs.¹ If so, you could be dealing with a SLAP (superior labrum, anterior to posterior) lesion.The glenoid 
labrum is a fibrous rim that attaches to the periphery of the glenoid fossa and helps to deepen it, thereby increasing the surface area of the glenoid. This deepening helps stabilize the humeral head - especially in the midrange of glenohumeral motion, at which point the ligamentous capsular structures are lax.²The labrum also serves as an attachment for the glenohumeral ligaments.

A SLAP lesion originates at the superior posterior labrum to the biceps anchor and extends anteriorly on the superior labrum. The proximal biceps tendon originates from the supraglenoid tubercle of the glenoid and blends into the fibers of the labrum and capsule surrounding this insertion. With type 1 and type 3 SLAP lesions, the biceps attachment to the labrum is intact; with type 2 SLAP and other such lesions, the biceps are pulled away from the glenoid attachment. This lack of a firm attachment of the biceps to the glenoid results in glenohumeral instability. Therefore, a labral injury may occur without biceps involvement, especially when the injury is of the compression type, such as those that occur as the result of a fall or repetitive compression from overhead throwing.³

The common type 2 SLAP lesion, in which the biceps tendon is detached, is usually a traction-type injury by which the biceps causes an avulsion of the superior labrum (deceleration phase of throwing). The patient also may complain of biceps tendinopathy, popping and clicking, due to the torn labrum. The superior laxity created by the loss of the biceps insertion may lead to damage to the posterosuperior porton of the rotator cuff, which may be associated with chronic SLAP problems. Rotator cuff injuries are not usually found in acute SLAP lesions.³ It appears that shoulder instability may stress the biceps insertion, leading to biceps detachment, or biceps detachment may lead to shoulder instability. Since the biceps tendon helps resist anterior translation, and supports the inferior glenohumeral ligament when the shoulder is in abduction and external rotation (cocking phase of the throw), if the shoulder is already unstable, the biceps are forced to overwork by increasing its protective compressive force, causing increased stress to the superior labrum and biceps tendon complex.

It has been proven that abduction and external rotation of the shoulder during the cocking phase of throwing stresses the origin of the long head of the biceps tendon, and its attachment to the posterior labrum.⁴

Kim, et al.,⁵ created a test for SLAP lesions that was positive mostly for the type Z lesion. The biceps load test II had a sensitivity of 89.7 percent; a specificity of 96.9 percent; a positive-predictive value of 92.1 percent; a negative-predictive value of 95.5 percent; and a kappa coefficient of 0.815. The test is performed as follows: The supine patient's arm is elevated to 120¡ and externally rotated to its maximal point, with the elbow in the 90¡ flexed position and the forearm in the supinated position. The patient is asked to flex the elbow while being resisted by the examiner. This is the position that reproduces the mechanism in the development of type 2 SLAP lesions.

Forceful traction of the displaced biceps-superior labral complex occurs during the active contraction of the biceps muscle against resistance. Kim, et al., believe the test position changes the relative direction of the biceps fiber in a position of an oblique angle to the posterosuperior labrum, causing a peeling of the superior labrum off the glenoid margin.

The test is positive if the patient complains of pain during resisted elbow flexion, or if the patient complains of more pain from the test than the pain that was already present in the test position. The test is negative if pain is not elicited by resisted elbow flexion, or if the pre-existing pain is unchanged or diminished by resisted flexion.

References

1. Kim S-H, Ha KK-I, Han K-Y. Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations. Amer J Sports Med1999; 27(3):300-307.
2. Lippett FG. A modification of the gravity method of reducing anterior shoulder dislocations.Clin Orthop 1982; 165:259-260.
3. Maffet MW, Lowe WR. Superior labral injuries. In: DeLee JC, Drez D. Orthopaedic Sports Medicine, Vol 1. Philadelphia: Saunders;2003.p.1046-1064.
4. Rodosky MW, Harner CH, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J sports Med1994;22:121-130.
5. Kim S-H, et al. Biceps load test II: a clinical test for slap lesions of the shoulder. Arthroscopy: The Journal of Arthroscopic and Related Surgery 2001;17(2):160-164.

Warren Hammer, MS, DC, DABCO
Norwalk, Connecticut 

Latest Test for Detecting SLAP Lesions

By Warren Hammer, MS, DC, DABCO

That painful clicking shoulder, especially in a thrower, could be a torn labrum usually referred to as a superior labral tear that is anterior to posterior in direction (SLAP) between the 10 and 2 o'clock position of the glenoid.

The labrum is located at the circumference of the glenoid cavity and is the attachment point of the shoulder capsule. Anchoring of the capsule to the glenoid labral rim is important for glenohumeral stability.¹ Tearing of the labrum, which is attached to the glenoid, is an indicator that the capsule also is not attached at that location. There are four main types of SLAP lesions with the most common being the type 2, the only type where there is an actual detachment of both the labrum and biceps that inserts into the labrum.¹

Physical examination for a shoulder labral tear is equivocal and it's disheartening to realize that most of the labral tests are not very sensitive or specific. Tests such as O'Brien, the crank test, Speed test, anterior slide, the compression-rotation test, biceps load and Yergason test are no longer considered predictive for SLAP lesions,^1,2 even when they reproduce a painful click. Kibler¹ stated that no single test is diagnostic and recommended at least five tests before making a decision. When the O'Brien test was first presented, O'Brien reported that his test was 100 percent sensitive and 98.5 percent specific for labral tears. Guanche, et al.,³ used arthroscopic evaluation before surgery to determine if particular labral tests were as valid as they were supposed to be and found the O'Brien test to be 63 percent sensitive and 73 percent specific.

He found similar results with other tests and concluded that a decision to proceed with surgery should not be based on clinical examination alone.³

Yang-Soo Kim, et al.,² discovered a new test for superior labral tears of the shoulder. They used what they call the Passive Compression Test (PCT), which was performed independently by two physicians as the first test before any other diagnostic evaluation including MR arthrogram imaging was used. All the lesions were eventually verified by arthroscopic examination and arthroscopic surgeries. Of the 61 shoulders examined, 31 demonstrated a positive PCT and 30 demonstrated a negative test result. Of the 31 patients with a positive test, 27 had confirmed SLAP tears. Of the 30 patients with a negative PCT, 24 had intact superior labra whereas the other six had confirmed SLAP tears at surgery. The sensitivity of the test was 81.8 percent and the specificity was 85.7 percent. The positive predictive value (PPV) was 87.1 percent and the negative predictive value was 80 percent. "Sensitivity" of a test is defined as the probability that patients who truly should have the positive response have that response when the test is performed. When a test has a very high sensitivity, a negative clinical finding effectively rules out the diagnosis. "Specificity" of a test is defined as the probability that patients who should truly have a negative response, express a negative response when the test is performed. PPV is the probability that a patient who receives a positive test result will truly have a positive response (the actual pathology tested for).¹ These percentages regarding the PCT are considered very good.

For the PCT, the patient lies sideways on the normal shoulder. The clinician stabilizes the shoulder at the acromioclavicular joint area with one hand and the patient's elbow with the other hand. Next, rotate the patient's shoulder externally with 30 degrees of abduction and then push the arm proximally (compressing the joint) while extending the arm. This should create a passive compression of the superior labrum onto the glenoid. All three motions should be performed at about the same time. The test is positive if it elicits pain or a painful click. The authors feel this test "reenacts the mechanisms of development of SLAP lesions." During external rotation and abduction of the humeral head, the long head of the biceps tendon is pulled laterally and will be under tensile tension as it wraps around the lesser tuberosity. This tension causes the superior labrum to shift from the superior glenoid rim. The second motion of extension of the shoulder with external rotation reproduces the late cocking phase of throwing. These motions have been found to increase the torsional stress at the origin of the long head of the biceps tendon and its attachment to the superior glenoid rim. The compressing of the humeral head "can aggravate the passive displacement of the unstable superior labrum on the glenoid."² Many SLAP injuries occur due to a fall onto an outstretched arm, creating a compression force to the shoulder.

The authors state that a false-positive result may occur if there is anterior instability of the shoulder determined by the anterior apprehension test or anterior drawer test. So this test will be most accurate if anterior instability is first ruled out. Let us hope that this test remains valid for awhile.

References

1. Hammer WI. Functional Soft-Tissue Examination and Treatment by Manual Methods, 3^rded. Sudbury, Mass.: Jones & Bartlett, 2007:33-161.
2. Yang-Soo Kim, Jung-Man Ha, Kee Yong, et al. The passive compression test: A new clinical test for superior labral tears of the shoulder. Am J Sports Med, 2007;35(9):1489-94.
3. Guanche CA, Jones DC. Clinical testing for tears of the glenoid labrum. Arthroscopy,2003;19:517-23.

Shoulder Lesions/LAG SIGNS

Lag Signs Are Important in Diagnosing Shoulder Lesions

By Warren Hammer, MS, DC, DABCO

Two primary ways of testing for rotator cuff ruptures is to determine whether the shoulder has enough strength to maintain a position against resistance, and by passive testing whereby the examiner attempts to determine if a passive position can be maintained in space (Lag sign).

Resistive tests are more likely to cause increased pain leading to reflex muscle weakness, even in the presence of an intact cuff.¹ Lag tests therefore may be more accurate since the arm is supported by the examiner and the pain level is decreased. Another reason this passive test may be superior to resistive testing for cuff rupture is that the influence of surrounding muscles, such as the deltoid and pectoralis major, is reduced.

A recent study² revisited the external rotation lag sign (ERLS). This test evaluates the integrity of both the supraspinatus and infraspinatus tendons. The ERLS is performed in the seated or standing position with the patient's elbow passively flexed to 90 degrees and the shoulder abducted to 20 degrees in the scapular plane, and near-maximal external rotation (minus a few degrees to avoid elastic recoil of the joint capsule or scapulothoracic joint caused by the examiner).

The examiner supports the elbow joint and holds the patient's wrist (Figure 1). The examiner then removes their hand from the wrist and asks the patient to actively maintain this position. If the patient cannot maintain original position against gravity and their arm rotates internally, the test is positive (Figure 2). The study2 concluded that this ERSL was "a useful sign for the diagnosis of isolated full thickness tears of the supraspinatus tendon." The amount of internal rotation lag for an isolated supraspinatus rupture was 7.35 degrees ± 3.12 degrees. This test should be compared with the contralateral side.

There was a strong correlation between the extension of the tear and the amount of the lag. As the lag (internal rotation) increases, there is most likely tearing of the infraspinatus and teres minor. For tears of the supraspinatus extending to superior and inferior portion of the infraspinatus, the lag was 17.76 degrees ± 9.55 degrees. If the teres minor is torn, the degree of internal rotation goes to 26.25 degrees ± 16 degrees.

The ERLS could not identify partial tears of the supraspinatus. The tests were confirmed by either arthroscopic or open surgery. The sensitivity was 56 percent and the specificity was 98 percent, meaning that if the test were negative, there was a 98 percent probability that there was not a full-thickness tear.

The ERLS test should be added to the tests recommended by the Parks, et al., study³ that found a 91 percent probability for full-thickness rotator cuff tears when there was a combination of a painful arc sign, drop-arm sign and a positive infraspinatus muscle test. For the drop-arm sign, the examiner holds the affected arm at 90 degrees of abduction (in the scapular plane) and at almost full external rotation, with the elbow flexed at 90 degrees. In this position, maintenance of the position of external rotation of the shoulder is a function primarily of the infraspinatus, but also stresses the supraspinatus. The patient is then asked to actively maintain this position as the examiner releases the wrist while supporting the elbow. The sign is positive if a lag or "drop" occurs. The magnitude of the lag is recorded to the nearest 5 degrees.

The lag sign for the subscapularis is performed with the patient's arm held in the lift-off position (behind their back, elbow flexed to 90 degrees, shoulder abducted 20 degrees, and extended 20 degrees). Examiner passively lifts the dorsum of the patient's hand away from the lumbar region until almost full internal rotation is achieved. The patient is then asked to actively maintain this position while the examiner, who is supporting the elbow, releases the patient's wrist.

If the patient cannot maintain the position and a lag toward the lumbar area occurs, then the subscapularis is ruptured. A slight lag indicates a partial tear of the cranial part of the subscapularis tendon, while an obvious drop of the hand may indicate a large tear.¹

References

1. Hertel R, Ballimer FT, Lambert SM, Gerber C. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg, 1996;5:307-313.
2. Castoldi F, Blonna D, Hertel R. External rotation lag sign revisited: accuracy for diagnosis of full thickness supraspinatus tear. J Shoulder Elbow Surg, 2009;18:529-534.
3. Park HB, Yokota A, Gill HS, et al. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg (U.S.), 2005;87:1446-55.

Lag Signs

By Thomas Souza, DC, DACBSP

We often assume that muscle testing about the shoulder will indicate the presence of a partial tear or full rupture of the rotator cuff muscles. Logically, if there is a partial tear or full rupture, active resisted testing of the muscle should cause painful weakness with a partial tear, and perhaps painless or minimally painful  weakness with a full rupture. 

Given that rotator cuff musculature and, in particular, tendon insertion, is largely hidden by more superficial musculature, the observation of a displaced tendon or bulge of a retracted muscle tendon is not obvious.

A common testing procedure is the drop sign, in which a patient's arm is elevated to 90 degrees and the patient is asked to hold the position. Inability to hold the position indicates involvement of either the deltoid or supraspinatus. Given that the supraspinatus is more often torn, the assumption is that a tear of the supraspinatus has occurred.

An extension of this concept is to add resistance to the position. This is often referred to as the Jobe sign. With the arm at 90 degrees abduction, the examiner exerts a downward force with the patient attempting resistance. The obvious confounding factor is that this test is likely to cause pain with many shoulder conditions, and the pain is likely to cause a reflex inhibition of the muscles. The weakness, then, is more a neurologic response rather than a biomechanical inability to hold the position.

Recently, Hertel et al.¹ performed an evaluation of 100 consecutive patients. The results of those patients who went on to arthroscopic or open repair of any rotator cuff muscle/tendon were examined to determine the effectiveness of several tests in detecting a partial or full rupture. The tests incorporated into the study evaluation were:

• The Jobe sign. The shoulder is elevated to 90 degrees abduction with internal rotation. The patient maintains position with the examiner exerting a downward force on the arm (similar to the "empty can" test).

• The liftoff test. The patient is seated with the hand of their involved arm placed palm outward on the lower back. The patient is asked to lift the hand off of the back.

• The external rotation lag sign. The patient is seated. The elbow is passively flexed to 90 degrees and the shoulder is held at 20 degrees elevation in the scapular plane in a position of near maximum external rotation (i.e., maximum external rotation minus five degrees to avoid elastic recoil). The examiner supports the elbow and holds the arm in external rotation at the wrist. The patient is asked to hold the position while the examiner supports the elbow but releases the hold at the wrist. The degree of movement is estimated and is referred to as the "lag" (i.e., the difference between active and passive ROM).

• The drop sign (different than the standard drop sign). The patient is seated. The arm is held at 90 degrees elevation (in the scapular plane) and almost full external rotation with the examiner supporting the elbow and holding the arm in external rotation at the wrist. The patient is asked to hold the position while the examiner supports the elbow but releases the wrist hold. The degree to which the arm falls into internal rotation is the degree of lag.

• The internal rotation lag sign. The patient is seated. The patient is asked to bring the arm behind the back with the palm facing outward. The arm is held in near maximum internal rotation and with the hand away from the back by approximately 20 degrees of extension. The patient is asked to hold the position while the examiner supports the elbow but releases the wrist hold. If the patient is unable to hold the position, the lag sign is positive.

The biomechanical principle used in the design of the lag signs was to place the muscle/tendon in the most disadvantaged positions possible, thereby requiring full function of the muscle. The position was also designed to eliminate, as much as possible, contribution from other synergists. False negatives may occur if there is a restricted passive movement pattern. False positives may occur if the arm is held in maximum rotation or if the patient has an excessive passive range of motion.

The results of the study indicate the following:

• For rupture of the supraspinatus and infraspinatus tendons, the external rotation lag sign was less sensitive but more specific that the Jobe sign. This is probably because the Jobe sign is often painful.

• The drop sign was the least sensitive, but was as specific as the external rotation lag sign.

• Partial ruptures of the supraspinatus were not revealed with the external rotation lag sign.

• For the subscapularis, the internal rotation lag sign was as specific but more sensitive than the liftoff sign.

• Partial ruptures of the subscapularis tendon could be missed with the liftoff sign but detected with the internal rotation lag sign.

Reference

1. Hertel R, Ballmer FT, Lambert SM, Gerber CH. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-13. 

SHOULDER PAIN

Upper Crossed Syndrome and Shoulder Pain

By Perry Nickelston, DC, FMS, SFMA

One of the most common injuries to afflict athletes of any skill level is shoulder pain. From the "weekend warrior" to the professional athlete, to the average fitness buff getting into shape; no one is immune to injury.

Beyond obvious traumatic onset, very few clinicians understand the mechanism for acute shoulder injury and chronic pain. The majority of shoulder problems develop from microtraumatic events occurring due to poor joint biomechanics and muscular movement imbalances. It is important for the clinician to be aware that shoulder pain is usually a symptom of deeper problems that, unless corrected, may lead to total functional impairment.

Clinical Perspective

Microtraumatic shoulder injuries happen in a predictable pattern: impingement >tendonitis > bursitis > rotator cuff injury. This leads us to the upper crossed syndrome (UCS). This syndrome is based on Dr. Vladimir Janda's pioneering work in researching and understanding the predictable pattern of muscular compensation and postural imbalances in the body. He postulated that faulty movement patterns on a poor postural base contribute to habitual overuse in isolated joints, while they minimize normal movement in others, thus creating a self-perpetuating cycle of dysfunction and eventual injury.

UCS leads to a forward head posture causing strain to the muscular attachments of the shoulder and shoulder blade. An anterior tilt and abduction ("flaring out") of the shoulder blades occurs, producing a rounded shoulder appearance. Due to the rounded shoulder posture, the mechanical axis of rotation of the glenoid fossa (shoulder socket) becomes altered. The humerus (arm) now requires additional stabilization from muscles that typically are quiet: the levator scapulae, upper trapezius, subscapularis, pectoralis minor and supraspinatus muscles. Postural overdevelopment of these muscles creates a deltoid shear (crossing of rotator cuff under AC joint), leading to shoulder impingement, tendonitis and bursitis syndromes.

Proper rehabilitation of the shoulder must include protocol for reversing the upper crossed syndrome. So, how do you do that? I have found the following program to be the most effective form of rehabilitation treatment.

Treatment Protocol

Due to chronic shortening, tightness and weakness in the primary stabilizers of the shoulder (supraspinatus, infraspinatus, teres minor and subscapularis), muscular adhesions and trigger points develop that must be removed before active/passive stretching. Failure to do so will result in stretch-reflex reciprocal inhibition and increased loss of muscle tone. Performing four to six sessions of myofascial release and trigger-point therapy usually is sufficient. Check all muscles in the UCS chart above. The most commonly affected muscles are the scalenes, pectoralis minor, infraspinatus and subscapularis.

Here are other aspects of this treatment protocol.

• Ultrasound the infraspinatus or subscapularis, depending on the most painful area of palpation and trigger-point referral pattern. Laser therapy also may be used. Typical dose is 170 Joules per point.
• Shoulder-blade retraction exercises for building the serratus anterior/posterior, trapezius and rhomboids, and for restoring scapular stabilization strength.
• Rotator cuff protocol: External rotation (three sets of 12-15 repetitions). Internal rotation not recommended due to the tendency of the subscapularis to become tight and overdeveloped.
• Y,T,W,L exercises on the stability ball to restore and enhance muscular recruitment patterns.
• Manipulation of the 5th and 6th cervical vertebrae and upper thoracics. Check the first rib for superior elevation, which can cause faulty AC joint mechanics, impingement syndrome and unrelenting trapezius muscle spasm.
• At-home treatment consists of rest and TENS to control pain. The tennis ball massage technique on the trapezius and infraspinatus (five to seven times per day) is extremely beneficial for breaking up active/latent trigger points. Self myofascial release with foam rollers on the upper back, lower latissimus dorsi, teres major/minor and infraspinatus will accelerate healing.

Most patients will be asymptomatic by the sixth visit and will demonstrate significant improvement in functional performance. The length of time it took to develop the problem is an indicator of how long you will need to work on correcting the faults before results will be felt. Don't forget that pain is often only the tip of the iceberg, directing you to the real underlying problem: upper crossed syndrome.

SHOULDER

Scapular Dyskinesis: Treatment With Elastic Therapeutic Taping

By Jennifer Illes, DC, Med. Ac., CKTI

Elastic therapeutic taping offers a unique combination of flexibility and support, providing practitioners with a tool to address a variety of conditions. Since 1973, when Kenzo Kase, DC, began developing the concepts in his practice, and then introduced its use in the 1980s, the range of applications has expanded tremendously.

Scapular dyskinesis, a factor in many shoulder complaints, is one of the many conditions that respond to this modality.

Shoulder pain is responsible for approximately 16 percent of all musculoskeletal complaints seen in the primary care setting,¹second only to low back pain in terms of patients seeking care for musculoskeletal ailments.² The problem some practitioners face is that traditional shoulder rehab fails 64-90 percent of the time because too much emphasis is placed on strengthening the rotator cuff (RTC) muscles using unidirectional isotonic strengthening³ – for example, conditioning the "mobilizers" of the shoulder (i.e., rotator cuff muscles) via bands and dumbbells.

What Is Scapular Dyskinesis?

Scapular dyskinesis describes an alteration in the normal static or dynamic position or motion of the scapula during coupled scapulohumeral movements. Other names for this condition include floating scapula and lateral scapular slide.⁴ As health care providers, we are concerned with scapular dyskinesis because alterations in scapular position and motion occur in 68-100 percent of patients with shoulder injuries.⁵

As the head of the humerus moves, the scapula simultaneously seeks a position of stability in relation to the humerus to maintain the humeral head in optimal alignment within the glenoid fossa. It is extremely important to note that scapular dyskinesis typically arises from a chronic shoulder condition (e.g., instability, labral tears, supraspinatous strain, impingement syndromes). As practitioners, therefore, we must first examine the shoulder to find the true pathology behind the scapular dyskinesis.

Scapulohumeral rhythm serves at least two purposes:

1. Preservation of the length-tension relationships of the glenohumeral muscles. When looking at a simple muscle physiology length-tension bell curve, one can note that both the hypertonic muscle (i.e., the one with too much overlap of actin and myosin filaments) and the hypotonic muscles (i.e., the ones with not enough overlap of the actin and myosin filaments) both produce a "weak" muscle. This is because both lack the proper length-tension ratio. With regard to the shoulder, the muscles do not shorten as much as they would without the scapula's upward rotation, so they can sustain their force production through a larger portion of the range of motion. Muscular imbalances can arise if the muscles lack a stable base of origin. Without muscular stability, muscles cannot develop maximal torque, resulting in decreased strength.


2. Prevention of impingement between the humerus and the acromion. Subacromial impingement can occur unless relative movement between the humerus and scapula is limited. Glenohumeral abduction is produced by force-coupling activity of both the RTC and deltoid, while the upward rotation of the scapula is produced by the serratus anterior and upper and lower trapezius muscles. We can implement elastic therapeutic taping techniques to facilitate these muscles to produce these motions, depending on what we find upon examination.

Common Causes of Scapular Dyskinesis

Postural abnormality: Many patients who present in our office have a visible upper-crossed syndrome. With increased cervical and thoracic spine flexion, there is a decreased upward rotation and decreased posterior tilt of the scapula.^6-7 These scapular abnormalities will cause decreased subacromial space and possibly an impingement-type syndrome of the shoulder.

Muscular contracture: This cause of scapular dyskinesis is particularly prevalent with patients suffering from upper-crossed syndrome. Tightness of the pectoralis minor or short head of the biceps can anteriorly tilt the scapula, due to their attachments to the coracoid process. Moreover, shortening of pectoralis major can restrict posterior clavicular motion (the clavicle should rotate posteriorly approximately 55° after 90° of shoulder abduction), thereby affecting normal scapular movement.

Muscle weakness (faulty movement patterns): Scapular muscle fatigue may lead to altered glenohumeral proprioception, muscular inhibition, and impaired coordination of scapular movements and timing. The most commonly inhibited hypotonic muscles are the serratus anterior, lower and middle trapezii, and rhomboid muscles. Inhibition is seen as a decreased ability for muscles to stabilize the scapula, and also as an unsystematic order of normal muscle-firing patterns. Most commonly, we tend to see this trend first with the serratus anterior and lower trapezius.

A Treatment Method Using Elastic Therapeutic Tape

There are several different ways to implement elastic therapeutic taping techniques. Each case is unique in that there are different shoulder and/or postural conditions that may cause scapular dyskinesis, and we may be dealing with these conditions in different phases of healing.

In the case modeled below (see images), I decided to tape for a fictitious impingement syndrome due to a subacromial bursitis causing a notable scapular dyskinesis. In the first image, inhibition was created on the upper trapezius by going from insertion to origin on the muscle belly. In addition, there is a facilitation piece of tape on the serratus anterior muscle from origin to insertion. Both of these pieces of tape were put on with the model with pre-stretched tissue tension. It is very important to facilitate the serratus anterior and/or lower trapezius musculature in this particular case.

The third piece of tape that was applied was a mechanical correction to try to proprioceptively reposition the scapula into posterior tilt. This piece of tape was anchored inferior to the coracoid process (second image) and then stretched with approximately 75 percent of tape tension while the patient had his arm into external rotation and abduction with slight extension. All three pieces of tape help to decrease the anterior tilt of the scapula, which would theoretically increase the space under the subacromial space.

Takeaway Points

Scapular dyskinesis can have many different etiologies; however, it is a secondary concern to another pathology or condition. It is for this reason that proper diagnosis must be made once a scapular dyskinesis is noted. In the case illustrated in the images above, elastic therapeutic taping can help the patient with facilitation and/or inhibition of muscles to help normalize muscular tone. By normalizing muscular tone, normal firing patterns – and therefore proper scapulohumeral mechanics – can possibly be restored. Taping can also be used to help create a mechanical correction of the scapula itself through proprioceptive receptors in the skin.

References

1. Van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis, 1995;54(12):959-964.
2. Steinfeld R, Valente RM, Stuart MJ. A common sense approach to shoulder problems. Mayo Clin Proc, 1999;74(8):785-794.
3. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg,2003;11:142-151.
4. Kibler WB. The role of the scapula in athletic shoulder function. Am J Sports Med, 1998;26(2):325-337.
5. Kibler WB, McMullen J. Scapular dyskinesis and its relation to shoulder pain. J Am Acad Orthop Surg,2003;11:142-151.
6. Ludewig PM, Cook TM, Nawoczenski DA. Three-dimensional scapular orientation and muscle activity at selected positions of humeral elevation. J Orthop Sports Phys Ther, 1996;24(2):57-65.
7. Finley MA, Lee RY. Effect of sitting posture on 3-dimensional scapular kinematics measured by skin-mounted electromagnetic tracking sensors. Arch Phys Med Rehabil, 2003 Apr;84(4):563-8.