1. Osteopathic Manipulative Medicine
Shoulder Pain
Stuart Williams, D.O.
Associate Professor
Osteopathic Manipulative Medicine

2. Evaluation of Shoulder
Glenohumeral Joint
Acromioclavicular Joint
Sternoclavicular Joint
T1-T4
Ribs 1-4

3. 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.

4. Upper Extremity Motion Test

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

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

7. 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

8. 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

9. Special Tests Rotator Cuff Pathology
Arm drop Test (Empty Can Test)

10. 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

12. Seven Stages of Spencer
Excellent way to examine shoulder while treating

13. Seven Stages of Spencer
1. Extension
2. Flexion
3. Circumduction with Compression
4. Circumduction with Traction
5. Abduction
6. Internal Rotation
7. Joint Pump

14. 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)

15. 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

17. 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

19. 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

21. 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

23. 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

25. 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

27. 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

29. Seven Stages of Spencer
1. Extension
2. Flexion
3. Circumduction with Compression
4. Circumduction with Traction
5. Abduction
6. Internal Rotation
7. Joint Pump