Shoulder Pain and Dis Function
Shoulder Pain and Dis Function
Shoulder Pain and Dis Function
Manual medicine
History of manual medicine:
• Manual medicine is as old as the science and art of medicine itself.
• Strong evidence shown in thailand 4000 years.
• Hipocrates,father of modern medicine.use traction for spinal deformity.
• In 19 th century found a renaiissance of interest,was a popular period of bone
setting in England and in the United States.
• 2 individuals who profoundlyinfluence the field of manual medicine:
• 1.Andrew Taylor Still MD(1828-1917) was a medical physician trained in the
preceptor fashion of the day. Proposed his phylosophy and practice Osteopathy.
• 2Daniel David Palmer(1845-1913).he was known as magnetic healer and became
self educated manipulative therapist.He is given credit for the origin of
chiropractic.
• In the first part of 20 th century,James Menell and Edgar Cyriax brought joint
manipulation recognition within the london medical community.
• John Bourdillon MD,a british- trained ortopedic- surgeon,he learned to perform
manipulation under general anesthesia and used the same techniques without
anesthesia.
• In the first part of 20 th century,James Menell
and Edgar Cyriax brought joint manipulation
recognition within the london medical
community.
• John Bourdillon MD,a British- trained
ortopedic- surgeon,he learned to perform
manipulation under general anesthesia and
used the same techniques without anesthesia.
• The practice of manual medicine should not be viewed in
isolation nor separate from regular medicine, and clearly is
not the panacea for all ills of humans.
• Manual medicine focuses on the musculoskeletal
system,which comprises more than 60% of human
organism and through of which evaluation of other organ
systems must be made.
• Manipulative medicine can be clinically effective in reducing
pain within the musculoskeletal system,in increasing the
level of wellness of patient and in helping patients with
myriads of disease processes.
• The goal of manipulation is to restore maximal pain free
movement of musculoskeletal system in postural balance
(Philip Greenman)
• Shoulder pain and dysfunction refer to pain
and decreased mobility localised to shoulder
region;base of neck,and the elbow but more
specifically to the region of deltoid
m,acromioclavicular joint,the sup part of
trapezius m,and the scapula
• Shoulder pain and dysfuction is characterised
by pain and decreased quality or quantity of
motion on active or passive movement of the
shoulder,is directly related to the shoulder
joints,articulations and muskuloskeletal origin.
• Preferred term that responds to manual
medicine is Shoulder somatic dysfunction.
Somatic Dysfunction
• Somatic dysfunction is the diagnostic criterion for which
manipulative/manual medicine is indicated.
• Definition of somatic dysfunction is as follows: Impaired or
altered function of related components of the somatic
(body framework) system: skeletal, arthrodial, and
myofascial structures, and related vascular, lymphatic,
and neural elements.
• Somatic dysfunction is treatable using manipulative
treatment.
• Criteria for diagnosis of somatic dysfunction;
• T .Tissue texture abnormalities.
• A. Asymmetry of bony landmark
• R. Range of quality of motion abnormalities.
• T. T enderness of temperature variations.
Epidemiology:shoulder pain and dysfunction
• Age:all,peak incidence:40-60years
• Gender:female
• Prevalence:most common msk disorder;UK;msk
complaints;Back
(23%),Knee(19%),shoulder(16%).
• Natural clinical course ;about 50% of all
episodes of shoulder dys.presenting in primary
care persist at least 1 year,regardless treatment
Common causes of shoulder pain and
decreased mobility
• Risk factor:
• Reduced mobility of the cervicothoracic junction has
an 84%predictive value for shoulder dys, and
increases the risk of developing disorder 3 fold.
• Depression;impaired conciousness
,elderly,spur,surgical intervention,th kyfosis,trauma.
• Work related risk factor;high level of
distress,repetitive shoulder motion,high job
demand,force and vibration.
• Associated conditions with pain and disability;
Ankylosing spondilitis,DM,fibromyalgia,
Multiple sklerosis,Neck dys,OA,polymyalgia,
Polineuropathy,RA,stroke.
Psychosomatic in adolescence.
Women living alone,smoking ,with social
support ,increase risk.
• Perpetuating Factors.
Adson’s Practicioner passively slightly abducts and Diminished pulse Compression or occlusion of
slightly extends patient’s arm on affected the subclavian artery as it
side and palapates patient’s radial pulse traverses between the
while patient turns head toward or away anterior and the middle
from the affected arm and inhales deeply scalene muscles( thoracis
outlet syndrome)
Apley’s scratch Patient touches superior and inferior Decreased range Rotator cuff dysfunction
aspects of opposite scapula
Apprehension Practicioner abducts affected arm to 90⁰, Pain or apprehension about Anterior glenohumeral
externally rotates and applies anterior impeding subluxation instability
pressure on the humerus.
“Clunk” With patient supine, practicioner A “clunk” sound or clicking Glenoid labrum disorder
passively rotates and flexes the affected sensation is heard or felt (tear)
shoulder through its range
Relocation Pracitioner performs this after a positive Decrease in pain or Anterior glenohumeral
apprehension test result with patient apprehension joint instability
supine.
Pracitioner applies a posterior force on
patient’s humerus while externally
rotating the arm.
Scapula winging Patient pushes against the wall with Medial scapula border Serratus anterior
pracitioner behind patient observing displays posterior weakness or injury
scapulae for symmetry and degree of displacement
“winged” apperance of medial border.
Speed’s Patient’s elbow is passively flexed to Pain or lateral or Biceps tendon
20-30 ⁰ and forearm is supinated medial movement instability or
with the shoulder flexed to 60⁰. The of the biceps tendonitis
pracitioner resists patient’s active tendon
attemps to further flex the affected
shoulder while palpating with the
other hand the proximal biceps
tendon at the shoulder.
Spurling’s With patient seated, patient actively Radicular pain or Cervical nerve root
extends his or her spine, and paresthesias in a impingement or
pracitioner passively rotates patient’s dermatomal inflammation
head to the side of the affected pattern
shoulder while pressing down on the
top of patient’s head.
Sulcus sign With patient’s elbow flexed to Shoulder Inferior glenohumeral
90⁰,pracitioner pulls downward on depression or joint instability
patient’s elbow or wrist and and sulcus upon
observes the shoulder for a sulcus or provoaction
depression lateral or inferior to the
acromion
Yergason’s Patient’s elbow flexed to 90⁰ with the Pain in the biceps Biceps tendon
forearm pronated. Pracitioner holds tendon ( long head) instability or
patient’s wrist and resists patient’s tendonitis
attempt to actively supinate and flex
the elbow fully.
Muscle energy techniques (MET)
Figure 17. Stage 5A, step 6. Figure 18. Stage 5A, step 7.
Figure 19. Reciprocal inhibition.
Stage 5B Adduction and External Rotation with
Elbow Flexed
1. The patient's arm is flexed sufficiently to allow the elbow to pass in front of the
chest wall.
2. The physician's forearm is still parallel to the table with the patient's wrist resting
against the forearm.
3. The patient's shoulder is adducted to the edge of the restrictive barrier (Fig. 20).
4. A slow, gentle (articulatory, make and break) motion (arrow, Fig.21) is applied at the
end range of motion.
5. Muscle energy activation: The patient lifts the elbow (black arrow, Fig.22) against
the physician's resistance (white arrow). This contraction is held for 3 to 5 seconds.
6. After a second of relaxation, the patient's shoulder is further adducted until a new
restrictive barrier is engaged (Fig.23).
7. Steps 5 and 6 are repeated three to five times, and adduction is reassessed.
8. Resistance against attempted adduction using the physician's thumb under the
olecranon process (reciprocal inhibition) has been found to be helpful in augmenting
the effect (Fig.24).
Figure 20. Stage 5B, steps 1 to 3. Figure 21. Stage 5B, step 4.
Figure .22. Stage 5B, step 5. Figure .23. Stage 5B, step 6.
Figure 24. Reciprocal inhibition.to control joint movement,
when a group of muscle is activated
The opposing group is inhibited
Stage 6—Internal Rotation with Arm Abducted,
Hand Behind Back
1. The patient's shoulder is abducted 45 degrees and internally rotated approximately 90
degrees. The dorsum of the patient's hand is placed in the small of the back.
2. The physician's cephalad hand reinforces the anterior portion of the patient's shoulder.
3. The patient's elbow is very gently pulled forward (internal rotation) to the edge of the
restrictive barrier (Fig..25). Do not push the elbow backward, as this can dislocate an
unstable shoulder.
4. A slow, gentle (articulatory, make and break) motion (arrows, Fig. 26) is applied at the
end range of motion.
5. Muscle energy activation: The patient is instructed to pull the elbow backward (black
arrow, Fig. 27) against the physician's resistance (white arrow). This contraction is held
for 3 to 5 seconds.
6. After a second of relaxation, the elbow is carried further forward (arrow, Fig. 28) to the
new restrictive barrier.
7. Steps 5 and 6 are repeated three to five times, and internal rotation is reassessed.
8. Resistance against attempted internal rotation (arrows) (reciprocal inhibition) has been
found to be helpful in augmenting the effect (Fig. 29).
Figure 25. Stage 6, steps 1 to 3. Figure 26. Stage 6, step 4.
1. Alpha motor eurons are efferent nerves from the ventral horn of the spinal cord that stimulate
the extrafursal muscle fibers to contract in response to central nervous system(i.e., brain and
spinal cord) demands
1. The Golgi tendon apparatus reports to the central nervous system the effect of the
eferent stimulus from the alpha motor neuron and enables refinement and further
• Muscle length is regulated by spinal nerves that innervate the muscle spindle in
• There are annulospiral and flower spray-type nerve endings within th emuscle
• The muscle spindle reports the changes of muscle length and the rate of change in
• Their excitation often causes the perception of pain, but they can be
stimulated without eliciting a pain sensations.
• They are capable of promoting pain and of inhibiting pain
• The peripheral nerves become sensitized, lowering their treshold of
activation and increasing their rate of firing.
as - aminobutyric acid (GABA)
• Sympathetic efferents from the spinal cord can modulate this neurogenic
inflammation
• Enchanced sympathetic output from hypersensitive spinal cord segments
induces palpable alterations in local temperature and hydration of soft tissues.
• Increased blood flow,heat and moisture in
acute stage of injury and inflammation under
influence of local vasoactive peptides and
nitric oxide can be modulate modulated by
sympathetic tone and decreased blood flow
,coolness and dryness in chronic stage.
• This leads to palpable abnormal tissue texture
(edema) and hyperalgesia(sensitivity to
touch)characteristics of somatic dysfunction.
Central peripheral nevous system
sensitization
• Beta afferent nerve stimulaton(i.e., nociception)
alters patterns of neural activityin the dorsal and
ventral horns of the spinal cord
Myofascial Adaptions
• Myofascial connetcive tissue matrix adaptions
accompany the articular and periarticular motion
restrictions and muscle imbalance
• Joint immobilization or prolonged periods of
decreased motion enable the formation of an
increased amount o collagen crosslinks that cause
myofascial connective tissue stiffness
• The fluid content and contractile elements
within these connective tissues adapt to
modify tensions and maintain biomechanical
integrity and efficiency of the region.
1. Glycosaminoglycans (GAGs) are generated
from fibrocytes in response to motion
Table 2.2 palpable skin changes from altered
blood flow due to somatic dysfunction
Acute Phase Chronic Phase
(hours to days) (weeks to months)
Hyperemic Ischemic
Warm Cool
Moist Dry
Sticky Slippery
2. GAGs are the linear polymers of repeating
disaccharide units that make up the ground
substance in the connective tissues
throughout the body
3. GAGs form the milieu in which the fibrous
collagenous fibers provide the form and
stiffness of the connective tissue.
4. GAGs are hydrophilic, and the amount of
GAGs present determines the relative fluid
content of the connective tissue
5. The more GAGs there are, the more water
binds to them, forcing the collagen fibers to
be farther apart and less able to form
crosslinks.
6. The fewer GAGs there are in the ground
substance, the stiffer and more noncompliant
in the connective tissue.
• Myofascial structures respond to sustained
stress forces (e.g., muscle spasms) by
undergoing deformation to accommodate the
load (i.e., creep). After the load is released,
the myofascial structures return toward their
initial state, but they never regain their exact
preload structure(i.e., hysteresis)