12 F is io te ra p ie , M aa rt 1982, d e e ! 38, n r 1 SHOULDER ASSESSMENT AND TREATMENT ACCORDING TO CYRIAX D O R O T H Y S W E A T M A N , M . C . S . P . a n d M e m b e r S o c i e t y o f O r t h o p a e d i c M e d i c i n e * S U M M A R Y I f c o r re c t d ia g n o sis o f th e sh o u ld e r j o i n t is m a d e tru e a n d e ffe c tiv e , tr e a tm e n t can b e c a r r ie d o u t b y p h y s io th e r a p y , in c o n ju n c tio n w ith a m e d ic a l p r a c titio n e r . T H E S H O U L D E R T h e s h o u l d e r is t h e m o s t r e w a r d i n g j o i n t t o t r e a t in th e w h o l e b o d y . O n c e t h e le sio n h a s b e e n i d e n t i fi e d , t h e r e is no j o i n t in t h e b o d y t h a t r e s p o n d s so well a n d so q u i c k l y to t r e a t m e n t . M a n y d i f f e r e n t l e s io n s exist b u t t h e y c a n all be d i s t i n g u i s h e d ; i d e n t i f i c a t i o n is m e r e l y a n ex er ci se in a p p l i e d a n a t o m y . T h e a s s e s s m e n t is p u r e l y c l i n i c a l , t h e p h y s i o t h e r a p i s t t e s t i n g t h e f u n c t i o n o f e a c h r e l e v a n t tiss ue in t u r n . D i f fi c u l t c as es d o exist, s u c h as p e r h a p s a d o u b l e lesion , o r a p a t t e r n h a r d t o i n t e r p r e t . In g e n e r a l it is b es t t o t r e a t the j o i n t fi rst , sinc e si g ns t h o u g h t t o i n c r i m i n a t e s o m e o t h e r ti ss ue o f t e n d i s a p p e a r as t h e j o i n t r e c o v e r s . T e n d i n o u s a n d c a p s u l a r l es ion s at t h e s h o u l d e r a r e q u i t e s e p a r a t e a n d ea ch m a y be p r e s e n t f o r y e a r s w i t h o u t a f f e c t i n g t h e o t h e r , a n d t h e y d o n o t m e r g e t o g e t h e r . T e n d i n o u s l e s io n s t h e m s e l v e s d o n o t limit t h e m o v e m e n t at t h e s h o u l d e r . L i m i t a t i o n o f a c tiv e m o v e m e n t c a n , o f c o u r s e , be d u e t o s u p r a s p i n a t u s t e n d i n i t i s , so p a i n f u l t h a t a n arc exi sts w h i c h p r e v e n t s t h e p a t i e n t f r o m r a i s i n g his a r m a b o v e t h e h o r i z o n t a l by his o w n e f fo r t s . B u t full p a ss iv e e l e v a t i o n r ela xe s t h e s u p r a s p i n a t u s m u sc le a n d th e a r m ca n b e r a i s e d w i t h o u t p a i n . H e n c e , t e n d i n o u s l es io ns d o no t limit th e p a s s iv e r a n g e o f m o v e m e n t a n d it is t h e p a ss iv e m o v e m e n t , n o t th e a c tiv e , t h a t i n f o r m s t h e e x a m i n e r w h a t th e t r u e r a n g e is. R E F E R R E D PAIN P a i n is r e f e r r e d o n a s e g m e n t a l bas is. S y m p t o m s ar i s i n g f r o m th e t iss u es at t h e s h o u l d e r a r e s e l d o m felt at the s h o u l d e r itself, t h e e x c e p t i o n b e i n g t h e a c r o m i o c l a v i c u l a r j o i n t a s it is d e v e l o p e d w i t h i n th e f o u r t h cer v ica l s e g m e n t a n d c a n n o t t h e r e f o r e r efe r p a i n t o t h e a r m . Al l o t h e r c o m m o n le s io ns a t t he s h o u l d e r af fe ct s t r u c t u r e s d e r i v e d l ar g el y f r o m t h e fifth ce rv ica l s e g m e n t , h c n c e t h e pair! is felt t o st a r t in the l o w e r d e l t o i d a r e a a n d t o s p r e a d a l o n g t h e r e l e v a n t d e r m a t o n e w h i c h e n d s at th e r a d i a l s id e o f t h e wrist. P a i n i n d i c a t e s t w o th in g s: • it o u t l i n e s t h e d e r m a t o n e a n d s h o w s t h e s e g m e n t w hi ch h as th e le sio n a n d • it i n d i c a t e s th e s e v e r i t y o f t h e les ion. T h e m o r e s e v e r e t h e le s io n t h e m o r e ex t e n s i v e the r e f e r e n c e o f p ai n. L e s i o n s c a n o c c u r in a n y o f t h e f o l l o w i n g s t r u c t u r e s at the s h o u l d e r : • C a p s u l e o f t h e s h o u l d e r j o i n t (C5). • S u b d e l t o i d b u r s a (C4). • A c r o m i o c l a v i c u l a r j o i n t (C4). • S u p r a s p i n a t u s t e n d o n (C5). • I n f r a s p i n a t u s t e n d o n ( C 5 / C 6 ) . • S u b s c a p u l a r t e n d o n ( C 5 / C 6 ) . * P r i v a t e P r a c t i t i o n e r . C a p e T o w n . R e c e i v e d 15 F e b r u a r y 1982. O P S O M M I N G A s d ia g n o se van d ie s k o u e r s u iw e r en e f f e k t i e f g e m a a k word, k a n b e h a n d e lin g d e u r fis io te r a p ie , in s a m e w e r k in g m e t ’n m e d ie s e p r a k tis y n , u itg e v o e r word. • L o n g h e a d o f b i c e p s ( C 5 / C6). • Bone . T h e r e is a l s o t h e p o s s i b i l i t y o f p a i n b e i n g r e f e r r e d t o t he s h o u l d e r f r o m t h e n e c k o r th e d i a p h r a g m (C4). B o n e d is e as e, a f r a c t u r e , o r a t u m o u r p r e s e n t little d i a g n o s t i c d if fi c u l t y sinc e th e p a t t e r n i n d i c a t i n g o n e t i s s u e o r a n o t h e r at t he s h o u l d e r is n o t i c e a b l y a b s e n t a n d the r a d i o g r a p h d i sc lo s es t h e r e a s o n . By c o n t r a s t t h e c a p s u l e o f th e s h o u l d e r j o i n t , t h e b u r s a e a n d t h e t e n d o n s a r e all r a d i o t r a n s l u c e n t ; h e n c e t h e X - r a y o f a p a i n f u l s h o u l d e r u s u a l ly r ev ea ls no a b n o r m a l i t y . M o s t p a t i e n t s w i t h a p a i n f u l s h o u l d e r ar e m i d d l e - a g e d . A n a r r o w j o i n t s p a c e o r a n o s t e o p h y t e is b o u n d t o be se en on th e X - r a y o f th e ce rv ica l s p i n e a n d t h e t e n d e n c y is t o t r e a t w h a t is s h o w i n g o n t h e X - r a y a n d n o t t h e r eal lesion . It is c o m m o n t o see cas es in w h i c h m o n t h s o f t r e a t m e n t h a v e been given in v a i n t o s y m p t o m l e s s s p o n d y l o s i s at t h e n ec k , i g n o r i n g t he p a i n f u l s h o u l d e r . W h e t h e r t h e p a i n a t t h e s h o u l d e r re s u l t s f r o m a loca l les ion o r is r e f e r r e d , c a n o n l y be d e t e r m i n e d by a cli ni cal e x a m i n a t i o n . E X A M I N A T I O N AT T H E S H O U L D E R T h e h is to r y is i m p o r t a n t in d i a g n o s i s a n d s e le ct in g t r e a t m e n t . Q u e s t i o n s m u s t be a s k e d as t h e a n s w e r s will he lp t o d e t e r m i n e t h e s t a g e t h a t th e le sio n h a s r e a c h e d — b u t if a t e n d o n is f o u n d t o b e i n j u r e d , n o n e o f t h e p o i n t s r a i s e d in the h i s t o r y a r e r e l e v a n t . N I N E Q U E S T I O N S • W h e re is th e p a in ? If a t th e s h o u l d e r , th e a c r o m i o c l a v i c u l a r j o i n t is s u g g e s t e d . P a i n in t he a r m , o n t h e o t h e r h a n d , is c o m m o n t o all o t h e r lesions. • W a s th e r e a n y in ju ry ? If a c a p s u l a r p a t t e r n is f o u n d , this su g g e s t s t r a u m a t i c a r t h r i t i s . • W h a t is th e p a t i e n t 's age? R e l e v a n t t o d i s t i n g u i s h the d i f f e r e n t t yp es o f a r t h r i t i s . • H o w lo n g h a s it b een p r e se n t? I f a c a p s u l a r p a t t e r n is p r e s e n t , thi s i n d i c a t e s a n a r t h r i t i s . • H a v e a n y o th e r j o i n t s b een a ffe c te d ? If a f f i r m a t i v e a n s w e r , thi s su g g e s t s r h e u m a t o i d o r a n k y l o s i n g s p o n d y l i t i s . • H a s th e p a in sp re a d ? T h e m o r e t h e p a i n g o e s d o w n the a r m , th e m o r e se v e re t h e les ion. • C a n th e p a tie n t lie on th a t sid e a t n ig h t? If n o t , a n d the c a p s u l a r p a t t e r n is p r e s e n t , t h e n t r e a t m e n t by f o r c i n g m o v e m e n t is i n a p p r o p r i a t e . • I s th e r e p a in b y d a y even w hen th e a r m is k e p t still? I f so, f o r c i n g is a g a i n c o n t r a i n d i c a t e d . • H a s su r g e r y e v e r b een p e r fo rm e d ? R e l e v a n t if th e p a t t e r n f o r m a l i g n a n t i n v a s i o n at t h e s h o u l d e r e m e r g e s . A c o m p l a i n t o f p a i n in th e s c a p u l a r a r e a a n d / o r a r m i n d i c a t e s a les ion in a ti ss u e f o r m i n g p a r t o f t h e C 4 - T 2 s e g m e n t s . T h e first a p p r o a c h t h e r e f o r e is a q u i c k r e v i e w o f all th e s e s e g m e n t s f r o m n e c k t o f in ge rs . T h i s p r e l i m i n a r y c h e c k c o u l d i n d i c a t e t h a t : R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) p h y s io th e r a p y , M a rc h 1982, v o l 38, n o 1 13 • T h e r e is s o m e t h i n g th e m a t t e r w it h th e s h o u l d e r o r • A le s io n exists b u t d o e s n o t lie at t h e s h o u l d e r o r • N o le sio n o f a m o v i n g p a r t exi sts b u t th e p a t i e n t is sinc ere , d r a w i n g a t t e n t i o n t o vi sc era l di se a se , s u c h as a n g i n a or p u l m o n a r y s u l c u s t u m o u r o r • T h e r e is n e u r o s i s o n th e b as i s o f m u l t i p l e in co n s is t e n c i e s . T h e e x a m i n e r m u s t n o t e r a n g e o f m o v e m e n t a n d p o w e r . T h e c a p su la r p a tte r n at t h e s h o u l d e r is t h a t o f m u c h l i m i t a t i o n o f a b d u c t i o n , m o r e l i m i t a t i o n o f l at er al r o t a t i o n a n d less l i m i t a t i o n o f m e d i a l r o t a t i o n . T a b l e l s h o w s d i f f e r e n t d e g r e e s o f se v e ri t y in th i s p a t t e r n . T A B L E I C a p su la r P r o p o rtio n s L a t e ra l M e d i a l A b d u c t i o n r o t a t i o n r o t a t i o n A rt hr it is l i m i t e d by li m i t e d by l i m i te d by Slight 10° OOr*', P a i n f u l at full ra n g e V Ioderate 45° 70° 10° Severe 70° 1 0 0 ° 2 0 ° T h e c a p s u l a r p a t t e r n o f l i m i t e d m o v e m e n t i n d i c a t e s a r t h r i t i s w h e t h e r o r n o t r a d i o g r a p h y d i s c lo s e s a n y a b n o r m a l i t y . A t ev e r y j o i n t in t h e b o d y s u p p o r t e d by m u s c le s , c a p s u l a r c o n t r a c t u r e t a k e s p l a c e in a c h a r a c t e r i s t i c w a y a n d h a s its i n d i v i d u a l c a p s u l a r p a t t e r n . W h a t e v e r th e n a t u r e o f the a r t h r i t i s , clin ica l e x a m i n a t i o n will r ev ea l l i m i t a t i o n o f r a n g e in th e c a p s u l a r p r o p o r t i o n s . T h e s y m p t o m s a n d end -feel in d i c a t e w h a t s t a g e t h e a r t h r i t i s h a s r e a c h e d . A t th e s h o u l d e r j o i n t t h e r e a r e t h r e e c o m m o n t y p e s o f a r t h r i t i s , viz. t r a u m a t i c a r t h r i t i s , m o n a r t i c u l a r r h e u m a t o i d a r t h r i t i s a n d o s t e o a r t h r o s i s . T h e r e is a n u n f o r t u n a t e te n d e n c y t o l u m p t h e m all t o g e t h e r u n d e r o n e b l u n d e r b u s s label n a m e l y “ f r o z e n s h o u l d e r ” , a n d th i s is n o h e l p as it d o e s n o t i n d i c a t e th e c a u s e , n o r w h i c h ti ss u e o f t h e j o i n t is af fe cte d. S in ce all t h e s t r u c t u r e s a r o u n d t h e s h o u l d e r h a v e a n a m e , t h e d i a g n o s i s s h o u l d b e spe cific. T h e p hy si c a l si g ns fall i n t o f o u r m a i n ca t e g o r i e s : • L i m i t e d p a s si v e m o v e m e n t — c a p s u l a r p a t t e r n . • L i m i t e d p a s s i v e m o v e m e n t — n o n - c a p s u l a r p a t t e r n . • Ful l p a s s i v e r a n g e , o n e r e s i s t e d m o v e m e n t h u r t s — t e n d i n o u s lesions. !• Ful l p a s si v e r a n g e — o n e o r m o r e m u s c le s a r e we ak . C L I N I C A L E X A M I N A T I O N T w e l v e m o v e m e n t s a r e c a r r i e d o u t . T h e e x a m i n e r n ot es r a n g e a n d p o w e r . T h e p a t i e n t m u s t r e p o r t t h e p r e s e n c e o r a b s e n c e o f p a i n . If a n y m o v e m e n t h u r t s , he m u s t in d i c a t e w h e r e it is felt, a n d i f i t is his s pe cif ic p a i n o r a n u n c o n n e c t e d ache. N E C K A c t i v e fl ex i o n , e x t e n s i o n , sid e flexio n to b o t h side s, a n d r o t a t i o n t o b o t h sides. S C A P U L A A c t i v e e l e v a t i o n ( C 3 / C 4 ) . S H O U L D E R A c t i v e e l e v a t i o n (C5). E L B O W R e s i s t e d fle x io n ( C 5 / C 6 ) ; r es is te d e x t e n ­ s i o n ( C l) . W R I S T R e s i s t e d e x t e n s i o n ( C 6 ); r es is te d flexion (C 7 )- T H U M B R e s i s t e d e x t e n s i o n ( C 8 ); r es is te d a d d u c ­ t i o n ( C 8 ). f i f t h f i n g e r R e s i s t e d a d d u c t i o n ( T l ) . I f thi s s u r v e y m a k e s it c l e a r t h a t t h e s h o u l d e r is at fa ult, th en t h e s h o u l d e r is e x a m i n e d in d e t a i l b y u s i n g twelve m o v e m e n t s . T h e Twelve M o v e m e n t s a r e • A c tiv e e le v a tio n T h e p a t i e n t is a s k e d t o b r i n g his a r m u p as h i g h as he ca n . T h e r a n g e o f a b d u c t i o n at the s h o u l d e r is 90°, w h e r e u p o n th e t u b e r o s i t y e n g a g e s a g a i n s t th e ed g e o f t he g l e n o i d foss a. T h e n e x t 60° o f e l e v a t i o n is b r o u g h t a b o u t by ac t i v e r o t a t i o n o f t he s c a p u l a , b u t w h e n t h e a r m h a s r e a c h e d the v e r t i c a l t h e last 30° o f e l e v a t i o n c o n s i s t s o f a d d u c t i o n o f th e h u m e r u s a c r o s s t h e f r o n t o f t h e s c a p u l a , n o w p o ss i b l e b e c a u s e t h e c o r a c o i d a n d a c r o m i o n p r o c e s s e s p o i n t u p w a r d s i n s t e a d o f f o r w a r d s . P a ssiv e e le v a tio n T h e e x a m i n e r p u s h e s t h e a r m u p as hi gh as it will g o a n d no tes : • T h e r a n g e o f e l e v a t i o n . • D o e s it c o r r e s p o n d w i t h t h e a c t i v e r an g e. • W h e t h e r p a i n is p r o v o k e d o r n o t . • T h e en d - fe el . W h e t h e r t he m o v e m e n t c o m e s t o a h a r d o r a soft s t o p at t h e e x t r e m e o f r a n g e ; thi s h a s c o n s i d e r a b l e d i a g n o s t i c si g n i f i ca n ce . P a in fu l a rc T h e p a t i e n t is a g a i n a s k e d t o b r i n g his a r m u p a n d t o sa y w h e n t h e p a i n b e g i n s a n d en ds . P a i n is e v o k e d as t he a r m p a s se s t h e h o r i z o n t a l , b u t is a b s e n t b e f o r e a n d a f t e r , t h u s a p a i n f u l a r c is p r e s e n t a n d it i n d i c a t e s t h a t t h e t e n d e r tiss ue lies in a p o s i t i o n w h e r e it ca n be p i n c h e d b e t w e e n the a c r o m i o n a n d t h e t u b e r o s i t y . T h e f o u r t iss ues in v o l v e d ar e s u p r a s p i n a t u s , i n f r a s p i n a t u s , s u b s c a p u l a r t e n d o n o r t h e s u b ­ d e l t o i d b u r s a . T h r e e p a s s i v e m o v e m e n t s a r e c a r r i e d o u t t o d e t e r m i n e the a m o u n t o f m o v e m e n t p e r m i t t e d by the c a p s u l e o f the s h o u l d e r j o i n t . P a ssiv e s c a p u lo h u m e r a l a b d u c tio n W i t h t h e t h u m b o f o n e h a n d fi x in g th e l o w e r a n g l e o f the s c a p u l a , t h e e x a m i n e r use s his o t h e r h a n d t o e l e v a t e th e a r m u n t i l he feels t h e s c a p u l a be g i n t o r o t a t e . T h e n o r m a l r a n g e is 90°. P a ssiv e la te r a l ro ta tio n T h e e x a m i n e r b e n d s t h e p a t i e n t ’s e l b o w t o a rig ht an g l e a n d u s i n g t h e f o r e a r m as a l eve r r o t a t i n g it o u t w a r d s . T h e n o r m a l r a n g e is 90°. P a ssiv e m e d ia l r o ta tio n T h e e x a m i n e r r o t a t e s t h e h u m e r u s a n d n o t e s h o w far b e h i n d t h e p a t i e n t ’s b a c k t h e f o r e a r m c a n be r o t a t e d . T h e n o r m a l r a n g e is 90°. N o w six re sis te d m o v e m e n t s a r e c a r r i e d o u t , o n e f o r ea ch g r o u p o f m u s c le s in t h e s h o u l d e r re g i o n . T h e e x a m i n e r m u s t a p p l y s t r o n g c o u n t e r - p r e s s u r e so t h a t th e j o i n t itse lf d o e s n o t m o v e . R e s is te d a b d u c tio n T h i s tes ts th e d e l t o i d a n d t h e s u p r a s p i n a t u s m u s c le s , b u t as p a i n f u l le s io n s o f t he d e l t o i d d o n o t o c c u r , p a i n on resis ted a b d u c t i o n i n d i c a t e s t h e s u p r a s p i n a t u s . R e siste d m e d ia l ro ta tio n T h is te s ts t h e p e c to r a lis m a jo r, te r e s m a jo r, la tiss im u s d o r s i, a n d s u b s c a p u la r is m u sc le s. S in c e th e m a in f u n c tio n o f t h e f ir s t th r e e m u sc le s is a d d u c t i o n , t h e s u b s c a p u la r is t e n d o n is s in g le d o u t i f a d d u c t i o n is p a in le s s. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 14 F is io te ra p ie , M aa rt 1982, d e e l 38, n r 1 R e siste d la te ra l ro ta tio n T h i s tes ts t h e i n f r a s p i n a t u s a n d te re s m i n o r m u s c le s . T h e l a t t e r is a n a d d u c t o r o f t h e h u m e r u s . I f lat er al r o t a t i o n alon e h u r t s , a t t e n t i o n is d r a w n to t h e i n f r a s p i n a t u s t e n d o n . R e siste d a d d u ctio n T h i s tes ts t h e t h o r a c o - h u m e r a l m u sc le s. R e sis te d f le x io n a t th e elbow T h i s tes ts t h e b i c e p s a n d b r a c h i a l i s m u s c le s ; i f r es is te d s u p i n a t i o n also h u r t s , t h e r e is a le sio n o f t h e b ic ep s . R e siste d exten sio n a t th e elbow T h i s t e s ts t h e tr ic ep s. RADIOGRAPHY I n t e r p r e t a t i o n o f t h e p a t t e r n t h a t e m e r g e s , a n d t h e r e s p o n s e s , w h e n t h e t w e l v e m o v e m e n t s are t e s t e d , e n a b l e s t h e e x a m i n e r t o d e t e r m i n e t h e le s io n p r e s e n t . O n l y n o w it is safe t o lo ok at t h e X - r a y p h o t o g r a p h . F r a c t u r e , n e o p l a s m , t u b e r c u l o s i s a n d os te iti s d e f o r m a n s ar e r e v e a l e d i f p r e s e n t . A s m a ll p a t c h o f c a lc if ic at io n o r a n o s t e o p h y t e m a y be se en , b u t it d o es n o t fo llo w t h a t e i t h e r is r e l e v a n t t o t h e p a t i e n t ’s s y m p t o m s . I n t h e o r d i n a r y ca s es o f a r t h r i t i s , b u r si t i s, o r t e n d i n i t i s it is u s u a l f o r n o a b n o r m a l i t y to b e d e t e c t a b l e o n X - ray. TREATMENT T r e a t m e n t at t h e s h o u l d e r is ve r y ef fe cti ve as l on g as t h e c o r r e c t d i a g n o s is h as b e e n m a d e . M o s t o f t h e les ion s r e s p o n d e x c e l l e n t l y t o d e e p cr os s f r i c t i o n m a s s a g e , o r i n j e c t i o n o f a s t e r o i d s u s p e n s i o n a n d s o m e o f t h e m r e q u i r e s t r e t c h i n g by t h e p h y s i o t h e r a p i s t . T he in te n tio n s are: • R e s t o r a t i o n o f a pa in le ss r a n g e o f m o v e m e n t • R e s to r a tio n o f p a i n l e s s f u n c t i o n t o . a t e n d o n • A b o l i t i o n o f b u r s a l i n f l a m m a t i o n Restoration o f P ainless Range T ra u m a tic a rth r itis ' I f t r e a t e d i n t h e ea r ly sta ges it c a n be a b o r t e d b y s t r e t c h i n g by a p h y s i o t h e r a p i s t i f t h e p a t i e n t p r e s e n t s w i t h t h e fo llo w in g c ri te ria : • A s h o r t h i st o r y . • N o p a i n e x c e p t o n m o v e m e n t . • T h e ab il it y to lie o n t h a t side. • N o p a i n b e l o w t h e elb o w . • E la st i c e n d feel. I f t h e c r i t e r i a i n d i c a t e t h a t t h e le sio n has b e c o m e to o a cu te f or s t r e t c h i n g , t h e p h y s i o t h e r a p i s t c a n ac hi ev e g o o d r e s u l t s by d i s t r a c t i o n t e c h n i q u e s , viz. pas siv ely d r a w i n g t h e h e a d o f th e h u m e r u s a w ay f r o m t h e gl en o i d . M o n a r tic u la r r h e u m a to id a rth r itis T h e r e s p o n s e t o i n t r a - a r t i c u l a r s t e r o i d i n j e c t i o n is i m m e d i a t e a n d n o o t h e r t r e a t m e n t is w o r t h us i n g . O steoarthrosis T h e c o n t r a c t u r e c a u s e d by o s t e o a r t h r o s i s r e q u i r e s s t r e t c h i n g b y t h e p h y s i o t h e r a p i s t . S t e r o i d i n j e c t i o n h e r e is use less. R estoration o f P ainless Function to a Tendon A sc ar in a s h o r t t e n d o n ca n be m a d e to t r a n s m i t m u s c l e p u l l p ai nl es sl y. By u s i n g d e e p cr o ss f r i c t i o n m a s s a g e to th e e x ac t site o f t h e sc ar, it is b r o k e n u p m e c h a n i c a l l y . T h e wh o le l e n g t h o f t h e sc ar m u s t b e t r e a t e d . I t is a p a i n f u l t r e a t m e n t b u t v er y ef fe cti ve a n d su c ce ss fu l. T h e t e n d o n c a n also be i n f il t r a t e d w i t h a s t e r o i d s u s p e n s i o n . A bolition o f Bursal Inflam m ation A c u te bursitis A n att ac k o f a c u t e b u r s i t i s can be a b o r t e d by i n f i l t r a t i n g th e e n t i r e b u r s a w i t h a s t e r o i d s u s p e n s i o n . C hronic bursitis T h e i n f i l t r a t i o n w i t h a local a n a e s t h e t i c s o l u t i o n o r st e ro i d is v e r y ef fective . TENDINOUS LESIONS T h e s e a r e c o m m o n at t h e s h o u l d e r b u t it is n o h e l p to say m e r e l y t h a t t h e r o t a t o r c u f f is at f a u l t — t h e spe cif ic p a r t o f t he c u f f m u s t b e d e t e r m i n e d . T h i s is n o t d i f fi c u l t sin c e ea c h p o ss es s a s e p a r a t e f u n c t i o n . T h e a f fe ct ed p a r t o f t h e t e n d o n m u s t be si n g l ed o u t b y ac c e ss o ry tests. T w o c r it er ia m u s t b e p r e s e n t be f o re t e n d i n i t i s ca n c o n f i d e n t l y b e d i a g n o s e d : • A fu ll r a n g e o f p a ssive m o v e m e n t m u s t exist at t h e s h o u l d e r join t. I t is m e c h a n i c a l l y i m p o s s i b l e f o r a p a i n f u l t e n d o n to i n t e r f e r e w i t h t h e r a n g e o f p a ssive m o v e m e n t b u t it m a y c a u s e p a i n w h e n s q u e e z e d u n d e r t h e a c r o m i o n o r at t he e x t r e m e o f r a n g e , i.e. t h e m o v e m e n t m a y h u r t at f u l l r an ge , b u t t h e r a n g e is fu ll a n d t h e e n d feel is soft. • T e s t i n g o n e g r o u p o f m u s c le s a g a i n s t r e s i s t a n c e h u r t s , b u t t e s t i n g t h e o t h e r g r o u p s p r o v o k e s n o d i s c o m f o r t . A c c e s s o r y t es ts ar e e m p l o y e d t o d e t e r m i n e w h i c h m e m b e r o f t h a t g r o u p is at f a u l t a n d i f p o s s i b l e w h i c h p a r t o f it. MUSCLE WEAKNESS W h e n a full r a n g e o f p a ssive m o v e m e n t is f o u n d , b u t a r e s i s t e d m o v e m e n t is wea k, t h e ca u s e is e i t h e r a n e r v e le sio n or a t e n d i n o u s r u p t u r e . CONCLUSION S o m e p e o p l e c o n s i d e r a p a i n f u l s h o u l d e r d i f fi cu lt to c o r r e c t — t h i s m i s t a k e n b e l i e f c o n d e m n s t h o u s a n d s o f p e o p l e to m o n t h s o f u n n e c e s s a r y p a i n a n d d i s a b l e m e n t . O n c e t h e les ion has b e e n i d e n t i f i e d by a s s e s s m e n t , w h i c h is p u r e l y clin ical, all t h a t is n e e d e d is a g o o d d o c t o r an d a c o m p e t e n t p h y s i o t h e r a p i s t w o r k i n g t o g e t h e r . T h e o n l y e q u i p m e n t r e q u i r e d ar e h a n d s , o r s y r i n g e a n d n e e d l e s , to s e c u r e lo ng l a s ti n g r e l i e f f r o m p a i n fo r t h e p a t i e n t . Reference C y r i a x , J . (1 978). T e x t b o o k o f O r t h o p a e d i c M e d i c i n e . Vol. 1. 7 t h E d . Ba ill ie re T i n d a l l . L o n d o n . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )