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Shoulder Muscle Power Deficits
ICD-9-CM codes : 840.6 Supraspinatus strain 726.12 Bicipital tenosynovitis
ICF codes : Activities and Participation Domain codes: d4452 Reaching (Using the hands and arms to extend outwards and touch and grasp something, such as when reaching across a table or desk for a book.) d4300 Lifting (Raising up an object in order to move it from a lower to a higher level, such as when lifting a glass from the table.) Body Structure code: s7202 Muscles of shoulder region Body Functions code: b7300 Power of isolated muscles and muscle groups
Common Historical Findings
Shoulder abductors/external rotators musculotendinous involvement : Pain in posterior-lateral shoulder Pain with overhead activities Midrange (about 90 degrees) catching sensation Symptoms developed from, or worsen with, repetitive overhead activities – or from an acute strain such as a fall onto the shoulder
Shoulder flexors musculotendinous involvement : Pain in anterior-lateral shoulder Pain with shoulder flexion and lifting activities Painful arc Symptoms developed from, or worsen with, repetitive flexion and lifting activities
Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions:
Shoulder abductors/external rotators musculotendinous involvement: Painful arc with active elevation Supraspinatus manual resistive test: weak and painful (moderately painful) Infraspinatus manual resistive test: weak and painful (mildly painful) Palpable posteriolateral rotator cuff tenderness Shoulder girdle muscle flexibility, strength, and coordination deficits
Shoulder flexors musculotendinous involvement : Painful arc with shoulder flexion Biceps brachii manual resistive test: weak and painful Palpable tenderness in bicipital groove Shoulder girdle muscle flexibility, strength, and coordination deficits
Physical Examination Procedures :
Normal Arm Elevation Painful Arc and Associated Motor Control Deficits Performance Cues: Common muscle flexibility deficits include short pectoralis minor, levator scapulae, teres major, and latissimus dorsi Common muscle strength deficits include weak supraspinatus, infraspinatus, lower trapezius, and serratus anterior Common motor coordination deficits include excessive 1) thoracic spine flexion, 2) contralateral weight shift of thorax, 3) scapular protraction and downward rotation, 4) scapular abduction during overhead activities
Supraspinatus Manual Resistive Test
Performance Cues: Elevate arm about 40 degrees in scapular plane “Thumb down” to internally rotate humerus Contact only dorsal surface of distal forearm Stabilize thorax - contact contralateral shoulder Remember - slow build-up of resistance, sustain peak, slow release of resistance If there is a grade III (complete) tear of the rotator cuff the patient will be unable to hold the arm in this position (positive “Drop Arm Test”)
Performance Cue: Placing the humerus in a position of internal rotation, extension, and adduction assists in gaining easier access to the tendons
Palpation of the Bicipital Groove
Shoulder Muscle Power Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term “ Rotator Cuff Tendinitis ”
Description: Repetitive strain injury to the deep tendons of the shoulder – most commonly the tendons of the supraspinatus of infraspinatus muscles.
Etiology: The suspected cause of this disorder is the abnormal “impingement” of the tendons of the rotator cuff between the humeral head and the acromial arch due to deficits in the ability of the humeral head depressors (the “rotator cuff muscles”) or the scapular upward rotator muscles to function in a coordinated manner during overhead activities.
Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes : b7300.3 SEVERE impairments of muscle power
- Accentuated thoracic kyphosis, scapular protraction, scapular abduction, and/or scapular downward tilt
- Excessive scapular elevation, abduction, downward rotation or winging with overhead reaching
- Midrange “arc” of pain with overhead movements (e.g., pain during 130o^ to 160o^ of shoulder flexion)
- Weak and painful supraspinatus and/or infraspinatus during manual muscle tests
- Palpation of involved rotator cuff tendons reproduce the patient’s reported pain complaint
Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes : b7300.2 MODERATE impairments of muscle power
As above, except:
- Strong and painful supraspinatus and/or infraspinatus
Now (when less acute) assess thoracic and scapular malalignments, and muscle flexibility and strength deficits – for example:
- Shortened pectoralis minor, levator scapulae, teres major, and latissimus dorsi myofascia
- Weak scapular upward rotator muscles – commonly lower trapezius, middle trapezius, and serratus anterior
Settled Stage / Mild Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes : b7300.1 MILD impairments of muscle power
As above, except:
- Strong and painful supraspinatus and/or infraspinatus muscles only with repeated contractions
- Midrange “arc” of pain only with repeated overhead movements
- Overpressure, or passively forcing end range shoulder flexion (e.g., “impingement tests”) reproduce the patients reported pain complaints
Intervention Approaches / Strategies
Acute Stage / Severe Condition
Goals: Alleviate pain with active arm elevation Restore strength to supraspinatus and infraspinatus muscles
- Physical Agents Ultrasound, iontophoresis, and/or ice applied to the rotator cuff tendons
- Manual Therapy Soft tissue mobilization to shortened pectoralis minor, levator scapulae, teres major, and latissimus dorsi myofascia
- Neuromuscular Reeducation Facilitate neutral thoracic cage and scapular posture with overhead activities
- Approaches / Strategies listed above
- Therapeutic Exercises Provide muscularendurance exercises to improve muscle performance of the relevant trunk, scapulae, and glenohumeral muscles required to perform the desired occupational or recreational activities
- Ergonomic Instruction Add job/sport specific training
Intervention for High Performance / High Demand Functioning in Workers or Athletes
Goal: Return to desired occupational or leisure time activities
- Therapeutic Exercises Provide exercises to maximize muscle performance of the relevant trunk, scapulae, and glenohumeral muscles required to perform the desired occupational or recreational activities
- Ergonomic Instruction Progress job/sport specific training to increase more mechanically demanding activities
Selected References
Bang MD, Deyle GD. A comparison of the effectiveness of two physical therapy treatment approaches for impingement syndrome of the shoulder: supervised exercise versus supervised exercise combined with manual physical therapy. J Orthop Sports Phys Ther. 2000;30:
Deyle GD, Bang MD. Examination and treatment of the shoulder. Orthopaedic Physical Therapy Clinics of North America. 1999;8:83-115.
Godges JJ, Matson-Bell M, Shah D, Thorpe D. The immediate effects of soft tissue mobilization with PNF on shoulder external rotation and overhead reach. J Ortho Sports Phys Ther. 2003;33:713-718.
Host, HH. Scapular taping in the treatment of anterior shoulder impingement. Phys Ther. 1995;75:803-812.
Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in etiology and treatment of impingement syndrome. J Orthop Sports Phys Ther. 1999;29:31-38.
Shoulder Muscle Power Deficits: Description, Etiology, Stages, and Intervention Strategies
The below description is consistent with descriptions of clinical patterns associated with the vernacular term “ Bicipital Tendinitis ”
Description: An inflammatory process involving both the tendon and its sheath within the intertubercular groove caused by repetitive strain injury to the long head of the biceps brachii tendon typically producing anterior shoulder pain.
Etiology: The suspected cause of this disorder is abnormal friction or strain of biceps tendon against the medial wall of the bicipital (intertubercular) groove. The structure of the anatomy leaves the tendon relatively unprotected. It is very important to recall that the bicipital groove acts as a trochlea, causing the tendon and its overlying sheath to be susceptible to wear and injury in this region. Eventually, fraying and narrowing of the tendon may occur with dense adhesions if the repetitive activities precipitating the condition are not ceased. It is important to differentiate between primary and secondary bicipital tendonitis. With primary bicipital tendonitis, the tendonitis is specific to the intertubercular groove without associated shoulder pathology. When the condition occurs in association with other pathologic conditions, such as impingement syndrome or rotator cuff disease, it is termed secondary bicipital tendonitis.
Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes : b7300.3 SEVERE impairments of muscle power
- Excessive scapular protraction
- Pain with lifting objects
- Pain with reaching and overhead activities
- Pain with shoulder flexion, lateral rotation or extension
- Weak and painful biceps brachii
- Tenderness to palpation over bicipital groove
Sub Acute / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions codes : b7300.2 MODERATE impairments of muscle power
As above with the following differences:
- Strong and painful biceps brachii contraction – e.g., pain with resisted shoulder flexion with the elbow fully extended
- Pain with resisted shoulder horizontal adduction with the shoulder in 90o^ of glenohumeral lateral rotation
In conjunction with the above findings, it is appropriate to examine the patient for common coexisting upper quadrant impairments in this stage.
- Posterior glenohumeral capsular tightness
- Coexisting upper thoracic or cervical disorders
- Manual Therapy Soft tissue mobilization and manual stretching to normalize the length of pectoralis major and coracobrachialis Friction Massage to the long head of the biceps brachii may be used to reduce adhesions of the retinaculum and tenosynovitic tissues in the intertubercular groove
- External Devices (Taping/Splinting/Orthotics) May consider a sling if necessary to temporarily limit painful active movements Taping to reposition the scapula in order to promote normal scapulohumeral rhythm when raising the arm.
- Neuromuscular Reeducation Facilitate neutral thoracic cage, scapular posture, and shoulder proprioception exercises Taping may also be used to train the patient to use weak, elongated muscles (e.g., lower trapezius) to function in a normal position
- Therapeutic Exercises Normalize the strength of the muscles commonly found to be weak, namely lower trapezius, serratus anterior, and perhaps the biceps brachii and brachialis
- Re-injury Prevention Instruction Temporarily limit shoulder flexion, lateral rotation, and overhead activities
Sub Acute Stage / Moderate Condition
Goals: Prevent re-injury of the biceps tendon Normal length and strength of the shoulder girdle musculature
- Approaches / Strategies listed above
- Therapeutic Exercises Manual stretching procedures and home/gym stretching exercises to the trunk and shoulder girdle muscles that have flexibility deficits Progressive resistive exercises to trunk and shoulder girdle muscles that have strength deficits. (Depending on the patient’s strength deficits, this may include instructing the patient in isometric, isotonic (e.g., tubing or free weights), and/or glenohumeral/scapular stabilization exercises (e.g., seated press-ups, progressive push-ups, Swiss ball exercises)
- Neuromuscular Reeducation Progression of strengthening exercises to regain normal coordination of rotator cuff and shoulder girdle musculature during functional activities. (Depending on the patient’s strength deficits, this may include instructing the patient in isometric,
isotonic exercises. For example, use of tubing or free weights for shoulder elevation, rows, scaption, curls and/or glenohumeral/scapular stabilization exercises such as seated press-ups, progressive push-ups, Swiss ball exercises)
- Ergonomic Instruction Modification of jobsite or other environmental factors as well as ergonomic cuing (movement training) to promote efficient, painfree, motor control of the trunk, scapulae and arm with lifting, reaching and overhead activities Modify activities to prevent overuse and re-injury
Settled Stage / Mild Condition
Goals: As above
- Approaches / Strategies listed above
- Therapeutic Exercises Progress activities to tolerance Maximize muscle performance of the relevant trunk, scapulae, shoulder flexion and shoulder girdle muscles required to perform the desired occupational or recreational activities
Intervention for High Performance / High Demand Functioning in Workers or Athletes
Goal: Return to desired occupational or leisure time activities
- Approaches/ Strategies listed above
- Ergonomic Instruction Progress job/sport specific training depending on the needs and desires and (impairments) of the worker or athlete
