Pathophysiology and clinical

assessment of the sporting shoulder

9-1-2024
2
Introduction

• 3de most common musculoskeletal disorder

• Up to 67% lifetime prevalence !

• 50% recovers within first 6 months

• An additional 10% during the 6 months afterwards
• 40% still has shoulder complaints after 1 year

80% of the total economic cost for shoulder pain

Luime et al. 2004, Ryall et al. 2006, Ottenheijm et al. 2011, Croft et al. 1996, Van der Windt et al. 1996,
Kuypers et al. 2006a,b
3
5
Ristori et al. 2018
Ristori et al. 2018
 NECK?
FOLLOW
SPINAL
GUIDELINES
 ABD SNN AC JOINT?
PAIN/WEAKNESS Guideline APPREHENSION- SC JOINT?
PROVOCATION? RELOCATION- NEUROLOGICAL
SYMPTOM RELEASE LEASIONS?
REDUCTION?
 Pathoanatomic diagnosis matters
Eg. Post op stiffness vs. Frozen shoulder vs.
Glenohumeral arthritis
 same impairments and level of irritability possible
 different prognosis & different rehab

L. Michener. State of the art and science for shoulder pain, Ghent 2017
L. Michener. State of the art and science for shoulder pain, Ghent 2017
L. Michener. State of the art and science for shoulder pain, Ghent 2017
L. Michener. State of the art and science for shoulder pain, Ghent 2017
Ristori et al. 2018
Suabcromial impingement syndroom?
Tendon overload and/or degeneration OR Mechanical
compression in subacromial space?
Specific tests?
Neer test
Hawkins/Kennedy
Empty can/ Jobe test
Apprehension (pain)
Rotatorcuff tests (integriteit?)
Droparm
Full can test
Lagtest m. Subscapularis (lift-of, belly press, ER
increase, IR lag sign…)
Lagtest m. Supraspinatus
Lagtest m. Infraspinatus
Lagtest m. Teres Minor (Hornblower’s sign)
Impingement?
Lewis 2022
Diagnostic value of shoulder tests?

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1

25
Results?
using the benchmarks of specificity >80%,
sensitivity >80%, LR+ ≥ 5.0 and LR− ≤0.20:

the apprehension, relocation, and surprise

tests to diagnose anterior instability

26
AIM = identify structure at fault ?

 Limitations of tests
 sensitive, not specific
 Confirms what the patient tells you: that their
painful shoulder is painful!
 Unrealistic to think that these tests selectively
tension specific structures
2 Using MRI could not distinguish between
people diagnosed with subacromial
impingement and age-matched controls
(Frost et al. 1999)
3 Acromiohumeral distance?
AHD at 60° shoulder abduction is negatively
correlated (r=-0.30; P<0.01) to the total score on
the SPADI.

Ledesma-Navarro & Struyf (Manual Therapy 2017)

4 Budoff et al. 2016 JSES
After a subacromial decompression, the rotator cuff has an
increased force production requirement to maintain baseline
glenohumeral mechanics
5 No difference in long-term development of rotator cuff
rupture and muscle volumes in impingement patients with or
without decompression Ketola S. et al. Acta Orthopaedica 2016; 87 (4): 351–355
140 impingement patients randomized to
a structured exercise group (n = 70)
an operative group (n = 70) +s tructured exercise post-op;
MRI of the shoulder was done at baseline and at 5 years.

Results: no statistically significant differences

6 Ellman H. 1990 Clin Orthop Relat Res.
Fukuda et al. 1987 Clin Orthop Relat Res.
Payne et al. 1997 Am J Sports Med

The majority of the rotator cuff issues seen tend

to occur on the humeral head side
7

The hypothesis that a reduction in subacromial space

is an extrinsic cause of impingement syndromes is not
conclusively established and the evidence permits no
conclusion.
8

In case of uncertainties, we should be open

minded and look for opportunities
Staged Approach for Rehabilitation Classification:
Shoulder Disorders (STAR-Shoulder) (McClure & Michener 2015)
Symptom Modification Procedures (Lewis et al. 2015)
 Terminology
ROTATOR
painful CUFF TENDINOPATHY?
arc syndrome
ROTATOR CUFF
subacromial RELATEDsyndrome
impingement SHOULDER PAIN?
Credible?
Supraspinatus tendinitis/tendinosis
supraspinatus syndrome
bursitis Acceptable?
swimmer's shoulder Not harmful?
thrower's shoulder
Subacromial pain syndrome
Rotatorcuff tendinopathy
Kukkonen et al. 2015 J Bone Joint Surg Am
Ketola et al. 2013 Bone Joint Res
Kuhn et al. 2013 J Shoulder Elbow Surg

Do we have a less invasive, less costly, and less

risky methods that is as effective?
Shoulder decompression does work for many patients

PT BIAS?
Specific tests?
Neer test
Hawkins/Kennedy
Empty can/ Jobe test
Apprehension (pain)
Salamh et al. 2020
 Implicaties voor klinische praktijk?

CAN?

Lewis 2022
Rotatorcuff tests (integriteit?)
Droparm
Full can test
Lagtest m. Subscapularis
Lagtest m. Supraspinatus
Lagtest m. Infraspinatus
Lagtest m. Teres Minor (Hornblower’s sign)
Challenges? Opportunities?
 Frozen shoulder

Millar 2022
Millar 2022
Millar 2022
 Plotseling (onverklaarbaar) verlies in ROM!

Risicofactoren?

Management?

Millar 2022
Shoulder instability
Specific tests

Apprehensiontest
Relocationtest
Release test
Sulcus sign?
Load and shift test?
A thorough Subjective Hx
• Traumatic/Atraumatic
Onset • Sudden/insidious/repetitive/voluntary

• Activity/dislocation related
Severity • At rest/Affect Sleep
• Related to weather or mood

• Specific
Pain • Diffuse
• Not related to displacement

Pain • Descriptors: Ache/Burning/electric shocks

Quality

• Fear/avoidance to move
Other • Adaptive postures
Factors
Shoulder instability

Jaggi 2010
Polar group I (traumatic structural instability)
Apprehension +
RC weakness (subscap)
Scapula ok
Global posture ok
Disruption capsulolabral
complex
Can evolve to (comorbid) group II or III
arthroscopy
Polar group II (atraumatic structural instability)
Apprehension +
Increased capsular
laxity (external ROM
increase) + sulcus sign +
GIRD
Scapular dyskinesis

Secondary to overuse
Polar group III (muscle patterning instability)
Aberrant activation of
large muscles (lat dorsi, pec
major, ant deltoid) and
simultaneous suppression of
the RC
Active subluxating
Generalised hypermobility
Posterior instability
BICEPS & SLAP LAESIES
Specific tests

Speeds test
Yergason test
O’Brien test
Biceps Load II (or pronated load test)
Upper cut manoever
BICEPS & SLAP LAESIES
Bicepspees luxaties
Biceps LH tendinopathie
SLAP laesies
Ruptuur

➔vaak post-operatieve fysiotherapie

59
US
Normale lokalisatie bicepspees
(Exorotation Sulcus
Intertubercularis)

Transverse
Biceps CL
US
MR
Biceps Tendon (Sub)luxation
62
Diagnose geassocieerd met impingement:
SLAP-LESIONS

= Superior Labrum
laesie van
Anterieur naar
Posterieur
 SLAP-LESION

Oorzaak?
Acuut trauma
Excessive load op bicepspees
tijdens de deceleratie en follow
through fase?
Peel-back phenomeen?
Acromioclaviculaire letsels
Specific tests
Resisted AC-compression test
Cross-body test
Joint-play
Palpation
(Lidocaïn injections)
Acromioclaviculaire letsels
Aandoeningen AC-gewricht

Voorkomen?
>

Oorzaken ?
Primair
Direct trauma >>>
Indirect trauma
Secundair
Letsels AC-gewricht
Klinisch onderzoek AC-letsels
Anamnese: pijn thv AC
Inspectie: (sub)luxatie AC-gewr.
/a/ abd: hoge painful arc
/p/ hor. add: pijn + beperkt
/p/ hor. abd: pijn + beperkt

pianotoetsteken
AC arthritis
Repetitieve irritatie AC
Last but not least…
Scapulaire dyskinesie
Wat vinden jullie?
McQuade 2016
Hickey 2018
Hogan 2021
Willmore 2016; Moghadam 2020
Lange 2016
Salamh (2023)
Schwank 2022
 Bern consensus statement

Schwank et al. 2022

Schwank et al. 2022
Schwank et al. 2022
 Key principles
Let irritability guide rehabilitation progression
Address clinically relevant GH ROM deficits using active
exercise therapy
Do address the scapula in rehabilitation, but do not screen for
dyskinesis
Select the appropriate exercise (open versus closed chain)
Include plyometrics early in a rehabilitation program
Train the brain (motor learning strategieën)
Sport-specific exercises

Schwank et al. 2022

RTS decisions
Zes domeinen

CONTEXT!
Pijn;
AROM;
Kracht, power en uithouding;
Kinetische keten;
Psychologische readiness;
Sport specifieke eisen

Schwank et al. 2022

Pijn

Overhead atleet: pijn mag bij terugkeer

naar participatie, pijnvrij bij RTPf.

Contact-sport atleet: pijn mag bij

terugkeer naar participatie, in een
gecontroleerde omgeving. Pijnvrij bij
RTPf.

STARRT-framework

Schwank et al. 2022

 AROM
Overhead atleet: volledige AROM niet voor
terugkeer naar participatie, wél voor RTPf.

Contact-sport atleten: lagere prioriteit, maar…

Eisen van de sport zijn belangrijk!

Schwank et al. 2022

 Kracht, power en uithouding
Peak force
RFD
…

Maar, wederom sport en positie specifiek!

Analyse van sport dus erg belangrijk. Rugby versus
tennis..

Schwank et al. 2022

Kinetische keten

Bewegingssequentie

Spiergedrag/ spierfunctie

Identificeren sub-optimale
beweegstrategieën

Attractors

Schwank et al. 2022

Psychological readiness

Fear of re-injury

Apprehension

Schwank et al. 2022

 Sport specifiek
Bewegingsprofiel sport van groot belang!

Schwank et al. 2022

Powell et al. 2022
Takeaways
Takeaways
Pathoanatomische diagnose ís belangrijk;
Patronen versus structuur;
Contextuele assessment;
Blijf kritisch!
Blijf up to date!
THANK
YOU