B REA KING THE PA IN CHA IN

The Variety of Possible

Causes in Shoulder Pain
dr. Ibrahim Agung, Sp.KFR

Divisi Muskuloskeletal - Departemen Rehabilitasi Medik

FKUI-RSUPN dr. Cipto Mangunkusumo
 Curriculum Vitae
dr. Ibrahim Agung, Sp. KFR
Birth date: 18 September 1986
EDUCATION
2017 International Fellowship of Physical Medicine and Rehabilitation at Chang Gung Memorial Hospital, Linkou,
(Republic of China) Taiwan
2012 – 2017 Physical Medicine and Rehabilitation Specialist at Medical Faculty; University of Indonesia
2004 – 2010 Medical Doctor at Medical Faculty; University of Indonesia
EMPLOYMENT HISTORY
September 2017 – now Physical Medicine and Rehabilitation Specialist at dr. Cipto Mangunkusumo
General Hospital – Jakarta
June 2018 – now Physical Medicine and Rehabilitation Specialist at Medistra Hospital – Jakarta
Maret 2018 – now Physical Medicine and Rehabilitation Specialist at RSUD Mampang Prapatan – Jakarta
September 2016 – now Clinical Director of Fun Fitness – Healthy Athletes; Special Olympics Indonesia
September 2010 – now Director of Babussalam Mosque Clinic, Jakarta, Indonesia
 Overview
1. Possible causes of pain (structural)
2. Anatomy and Kinesiology
1. Biomechanic
2. Scapulohumeral rhytm
3. Patomechanic
4. Three level diagnosis
5. Treatment approach
1. Biomechanical correction
 Introduction
• The third leading cause for patients seeking musculoskeletal care

• The impact of shoulder pain on health-related quality of life also substantial

• It is important to obtain history, physical examination and relevant

investigation, which are essential in making the diagnosis

• For many disease entities, a diagnosis can be accurately reached even

without the use of imaging studies

• Not all of shoulder pain can be diagnosed with FROZEN SHOULDER

 Introduction
• The upper extremity is attached to the trunk by flimsy
articulation → mutually interdependent in producing a
smooth series of movements called the SCAPULO-HUMERAL
RYTHM

• These articulation are called the SHOULDER GIRDLE or

the THORACO-SCAPULAR-HUMERAL articulation
 Possible causes of pain (structural)
CLASSIFICATION
The causes for shoulder pain can be classified as follows
NON TRAUMATIC (Intrinsic Causes) NON TRAUMATIC (Extrinsic Causes)
1. Glenohumeral 1. Disc herniation with neural
1. Rotator cuff tendinopathy impingement at C5 or C6 level
2. Rotator cuff tear
2. Cervical spinal canal stenosis
3. Subacromian bursitis →
Impingement 3. Long thoracic and suprascapular
4. Glenohumeral arthritis neuralgia
5. Glenohumeral instability 4. Referred pain
6. Labral tear
1. Myofascial pain syndrome
2. Extra glenohumeral (commonly trapezius)
1. Bicipital tendinopathy
2. Myocardial ischemia
2. Acromioclavicular artrhitis
3. Subscapular bursitis
3. Intrathoracic tumors
 Possible causes of pain (structural)
CLASSIFICATION
The causes for shoulder pain can be classified as follows

TRAUMATIC RED FLAGS

1. Fracture clavicle
2. Fracture humerus
3. Glenohumeral dislocation
4. Acromioclavicular ligament sprain
1. Tumor
2. Acute rotator cuff tear
3. Unreduced dislocation
4. Infection
5. Unexplained significant sensory and
motor deficit
6. Pulmonary or vascular compromise
Sources of Pain
GLENOHUMERAL JOINT
Joint
- Ball shaped head of the humerus &
shallow concave glenoid fossa
- Discrepancy in the joint shape:
- Head of humerus: 1530
- Glenoid fossa: 75 0

- Fibrous ring at the fossa perimeter:

glenoid labrum

Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.

ROTATOR CUFF MUSCLES
 1. GLENOHUMERAL JOINT:
Joint Movement: Scapulo-humeral Rhytym
▪ Glenohumeral movement requires
simultaneous abduction of the arm with
the depression of the humeral head →
coordination of rotator cuff muscles
and deltoid → SCAPULOHUMERAL
RHYTHM

▪ Deltoid: elevates humerus against

coracoacromial hood
▪ Supraspinatus: fixing humeral head to
glenoid fossa
Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.
 1. GLENOHUMERAL JOINT:
Joint Movement: Scapulo-humeral Rhytm
• The first 30 degrees of shoulder
joint motion is pure shoulder joint
motion.

• However, after that, for every 2

degrees of shoulder flexion or
abduction that occurs, the scapula
must upwardly rotate 1 degree.
This 2:1 ratio is known as
scapulohumeral rhythm.

Reyes, TM., Reyes, OBL. Kinesiology. Vol. 4. UST : Philipines.1978.

 Gabungan Gerakan pada Gelang Bahu
Abduction of arm
2 : 1
Glenohumeral Joint : Scapular Rotation

• Full elevation of arm:

– 120° GH joint + 60° Scapular Rotation
• Internal rotation:
– only 60° humeral abduction
• External rotation:
– 90° actively abducted
– 120° passively abducted’
• Di dalam persendian suprahumeral ditemukan berbagai jaringan
yang sensitif, yaitu:
1. Bursa subacromial
2. Bursa subcoracoid
3. Tendon supraspinatus
4. Bagian superior capsul
glenohumeral
5. Tendon biceps
6. Jaringat ikat
 Pain history
• Location.
– Anterolateral → biceps, subscapularis, supraspinatus
– Posterior → infraspinatus, teres minor
• Activities
• Nocturnal pain
• Radiating pain, tingling and numbness
• Past history
• Systemic illness → DM
 Physical Examination
• Inspection • Special test
– Empty can test → supraspinatus
• Palpation → surface
– Belly press test → subscapular tear
anatomy – Neer’s test; Hawkins-Kennedy test →
• Range of motion Impingement test
– Drop arm test → supraspinatus tear
• Muscle strength
– Apprehension test → subluxation
– O’Brien test → AC Joint
– Speed test; Yergason Test → bicipital
tendinitis
 Investigations
• Plain X ray
– Fracture proximal humerus
– GH dislocation
– GH OA
• Ultrasonography
• MRI
• Intervention (Diagnostic
Blocks)
Adhesive capsulitis
Biomechanical change related to pain
 Three level diagnosis
• Level 1 →Symptoms • Level 1 → Shoulder pain

• Level 2 → Biomechanical • Level 2 →

changes – Narrowing subacromial space
– Eccentric contraction of
muscles
• Level 3 → Structural
changes/deformities
• Level 3 → shoulder
impingement
 Goals of treatment
• Control/reduce pain
• Increase ROM
• Maintain muscle strength
• Independent and functional ADL
• Prevent pain recurrent
 Treatment options
1. Oral medication
• Level 1 → Shoulder pain 1. Pain killer
2. Anti inflammation
• Level 2 → 3. Muscle relaxant
– Narrowing subacromial 4. Neuroprotector
space 2. Physical therapy
– Eccentric contraction of 1. Modalities: Laser,
muscles Diathermy
2. Manual therapy
3. Intervention
• Level 3 → shoulder
4. Biomechanical correction
impingement
1. Good Posture
2. Exercises
Rehabilitation intervention
 Take home massages
• Many source of shoulder pain can be identified with specific
anamnesis and physical examination

• Comprehensive diagnosis lead to the right treatment

• Inaccurate treatment lead to Adhesive capsulitis/Frozen Shoulder

• Biomechanical change is the key to reduce pain and prevent

recurrent pain
THANK YOU