Osteopathic Manipulative Medicine 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

Upper Extremity Motion Test 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

Rotator Cuff Muscles SITS Supraspinatus-abduction Infraspinatus-ext.rotation Teres Minor-ext. rotation Subscapularis-int. rotation

Special Tests Apley Scratch Test and Shoulder ROM External Rotation & ABduction Internal Rotation & ADduction Internal Rotation & ADduction

Upper Extremity Tie-Down Muscles Hold UE to axial skeleton Latissimus dorsi Trapezius Rhomboid major & minor Levator scapulae Pectoralis major & minor Deltoid Serratus anterior Subscapularis Anterior scapular fossa to lesser tuberosity of humerus Teres major Lateral border of scapula to medial aspect of humerus Latissimus dorsi Thoracolumbar fascia and T6-T12 to medial side of bicipital groove of humerus Trapezius Base of skull to T12 to lateral 1/3 of clavicle, acromion, and spine of scapula Transmission of thoracic pain to shoulder Rhomboid major and minor C7 through T5 to medial border of scapula Hold scapula to body and help with retraction of scapula Levator scapulae C1 through C4 to superior aspect of medial border of scapula Pectoralis major Medial 1/3 of clavicle, sternum and costal cartilages 1-6 to lateral aspect of biccipital groover of humerus Pectoralis minor Ribs 3-5 to coracoid process Deltoid Lateral 1/3 of clavicle, acromion and spine of scapula to deltoid tuberosity of humerus

Shoulder Range of Motion 180º 30-45º 90º 45-50º 55º 40-45º Glenohumeral and Scapulothoracic Joint ABduction ADduction Flexion Extension Internal Rotation External Rotation

Special Tests Rotator 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