Shoulder Pain
Stuart Williams, D.O.Associate Professor
Osteopathic Manipulative Medicine
Evaluation of Shoulder Glenohumeral Joint Acromioclavicular Joint Sternoclavicular Joint T1-T4 Ribs 1-4
Patient abducts arms and extends pronated hands over head
Negative Test Upper arms should touch ears Elbows straight. Forearms pronated. Back hands approximate equally. Joints of shoulder, elbow, radioulnar, and wrist
are normal. Positive Test
Patient unable to bring forearms to ears, straighten elbows, or approximate back of wrists.
Check shoulders, elbows, and wrists. Also check upper ribs and upper T-Spine.
Upper Extremity Motion Test
Upper Extremity Motion Test
Rotator Cuff MusclesSITS
Supraspinatus-abductionInfraspinatus-ext.rotationTeres Minor-ext. rotation
Subscapularis-int. rotation
Special TestsApley Scratch Test and Shoulder ROM
External Rotation & ABduction
Internal Rotation & ADduction
Internal Rotation & ADduction
Shoulder Range of Motion
Glenohumeral and Scapulothoracic Joint ABduction ADduction Flexion Extension Internal Rotation External Rotation
180º30-
45º90º45-
50º55º40-
45º
Special TestsRotator Cuff Pathology
Arm drop Test (Empty Can Test)
Adhesive Capsulitis“frozen shoulder” Gradual loss of function Decreased ROM - Active and
Passive External Rotation Internal Rotation ABduction
Diffuse tenderness
Inflammation Fibrous changes in periarticular
soft tissue Decreased joint volume -
confirmed by arthography
Seven Stages of Spencer Excellent way to examine shoulder
while treating
Seven Stages of Spencer 1. Extension 2. Flexion 3. Circumduction with Compression 4. Circumduction with Traction 5. Abduction 6. Internal Rotation 7. Joint Pump
Technique (Muscle Energy) Contact usually over elbow, but you are
moving humerus to muscular barrier Patient instructed to move in opposite
direction isometrically D.O. offers counterforce (isometric) Patient & D.O. stop. Wait for tissue to
relax (2-3 sec) Carefully take up slack to next barrier Repeat until best motion (usually 3
times)
Stage 1 - Extension Cup cephalad hand over clavicle
and scapula Flex elbow and carry humerus into
extension to restrictive barrier Apply muscle energy activation
(patient flexes against you while D.O. offers counterforce) On relaxation, carry humerus to further extension
Stage 2 - Flexion Caudad hand stabilizes clavicle and
scapula Flex humerus to restrictive barrier
should have 180° arc motion Apply M.E. to active (patient attempts to
extend shoulder against counterforce) Relaxation (wait 2-3 seconds) Carry shoulder in flexion to new barrier Repeat 2-3 times as needed
Stage 3 – Circumduction with Compression Cephalad hand cups clavicle and
scapula to stabilize Flex elbow and abduct humerus to 90° Compress gently to seat head of
humerus in glenoid fossa Circumduct elbow clockwise and
counter-clockwise in a cone shape Any areas of resistance-modify elbow
pressure and change circumference of cone
Stage 4 – Circumduction with Traction Cephalad hand cups clavicle and
scapula to stabilize Grasp wrist and apply traction Circumduct arm in cone-like
fashion both clockwise and counter-clockwise
Any areas of resistance, modify the arm traction and/or change circumference of the cone
Stage 5 - Abduction Cephalad hand continues to cup
clavicle and scapula to stabilize Patient flexed at elbow Adduct humerus to restrictive
barrier Apply muscle energy activation
(patient adducts against D.O.) On relaxation (wait 2-3 seconds),
carry to new barrier
Stage 6 – Internal Rotation Cephalad hand cups clavicle and
scapula Place patient’s hand behind L/S area Internally rotate humerus by moving
elbow anteriorly Active muscle energy (patient externally
rotates against resistance) Have patient relax. Wait 2-3 seconds.
Internally rotate to new barrier
Stage 7 – Joint Pump Extend patient’s elbow Abduct patient’s humerus Place patient’s hand on your
shoulder Place your hands and fingers over
humeral head Apply caudal force with a scooping
pumping action
Seven Stages of Spencer 1. Extension 2. Flexion 3. Circumduction with Compression 4. Circumduction with Traction 5. Abduction 6. Internal Rotation 7. Joint Pump