Shoulder Pathologies

Inferior/Multidirectional instability

- a combination of 2 or more unidirectional instabilities; may be congenital, presenting with generalized hyperlaxity without a history of trauma (patients typically participate in overhead activities that impose repetitive micro trauma) - goal of evaluation is to perform unidirectional assessments and add results together - dynamic restraints to inferior translation: rotator cuff musculature - static restraint with humerus in neutral: superior GH ligament - static restrain with humerus adducted to 45-90 degrees (neutral rotation): inferior GH ligament - conservative management: generally managed conservatively, focus on strengthening scapular stabilizers and rotator cuff musculature (focusing exercises to improve only one instability direction may make MDI worse)

Hill-Sachs lesion

- bony defect of the posterior humeral head - occurs as the humerus shears over the anterior glenoid - rarely symptomatic - primary complaints: mechanical sounds (popping/locking/clicking); deep shoulder pain

Subacromial bursitis

- chronic rotator cuff impingement or rotator cuff tears, if untreated, ultimately lead to inflammation of the subacromial bursa and still further encroachment of the subacromial space. - since they often occur concurrently, it is difficult to differentiate between rotator cuff pathology and subacromial bursitis - subacromial bursitis causes positive results from impingement tests and tests for supraspinatus tendinopathy as the 3 conditions are often related - treatment strategy: non-surgical approach to manage patients with rotator cuff tendinopathies emphasize an approach that addresses impairments that alter function and modification of activity as necessary. Strengthening must focus on the scapular musculature, the rotator cuff, and other shoulder muscles. (Strength of legs and trunk must also be analyzed)

Bankart lesion

- inferior GH ligament avulses from the labrum causing a tear - could be a bony bankart lesion (anteroinferior labrum avulses from glenoid) - primary complaints: shoulder pain, feelings of instability as the head of the humerus moves against anterior labrum during - GH joint play assessment, load and shift, or external rotation assessment - mechanism: dislocation or subluxation

Posterior instability

- mechanism: A. Non-traumatic - repetitive forces that force the humeral head posteriorly (ex. Blocking); forces that distract the posterior GH structures (ex. Follow through of overhead throw); weakness or fatigue of subscapularis and infraspinatus muscles B. Traumatic - following subluxation (similar provocation tests may indicate lingering posterior instability - mechanism for traumatic: FOOSH (axial load on hand with arm adducted and IR), arm flexed forward with a posteriorly directed force, seizure or electrocution - primary complaints: pain during movements requiring horizontal adduction while loading the posterior joint capsule - conservative treatment: first option, focus on strength and endurance of infraspinatus muscle - surgical management is warranted with clear structural pathology (I.e. posterior labral tear)

Biceps tendinopathy

- mechanism: bicipital tendon pathology may result from rotator cuff dysfunction, from overuse of the biceps brachii muscle, or from subacromial impingement - the transverse humeral ligament, which holds the tendon in the bicipital groove, may become stretched or torn as the result of sudden forceful extension or external rotation of the shoulder accompanied by elbow flexion (disruption of the transverse humeral ligament can cause the LHBT to sublux from the bicipital groove, especially when the elbow is flexed and the humerus is externally rotated) - the LHBT provides very little force in moving the GH joint - due to the insertion of the LHBT into the glenoid labrum and intraarticular nature, pathology of this structure can impact the joint's function - during normal overhead movements, the tendon slides within its sheath, which is located in the bicipital groove - often occurs simultaneously with rotator cuff tendinopathies - special tissue tests: yergason's test (reproduce subluxation of the LHBT or cause pain associated with bicipital tendinopathy) and speed's test (only has positive test is the presence of bicipital tendinopathy) - imaging: MRI can be used to differentiate between subluxation LHBT and bicipital tendinopathy - treatment strategy: conservative rehabilitation includes decreasing inflammation with the use of oral medications and activity modification. Stretching and strengthening of the shoulder complex muscles should progress in a manner similar to that used for rotator cuff tendinopathies. Recalcitrant bicipital tendinopathy can be managed operatively with a tenotomy (cutting the tendon) or tenodesis (repositioning the tendon). Both procedures are associated with favorable outcomes, although the tenotomy is associated with a worse cosmetic result

Anterior GH instability

- mechanism: can result from either repetitive overload (non-traumatic) or following an acute dislocation/subluxation (traumatic) A. Non-traumatic - repetitive shoulder movements that cause anterior shear force across the GH joint (ex. Overhead throwing - late cocking and early acceleration phases); static stabilizers fatigue and begin to stretch so the dynamic stabilizers must compensate but eventually fatigue too as throwing continues (symptoms of weakness and instability result) - caused by: damage to anterior stabilizers (middle GH ligament, anterior band of inferior ligament) and secondary contributors (superior GH ligament, dysfunction of LHBT, rotator cuff tears or weakness) - intervention strategies: A. Non-traumatic - typically managed conservatively, unless clear tear of static or dynamic stabilizers is seen; brief period of immobilization to manage pain; gradual strengthening program focused on anterior stabilizers and scapular stabilizers B. Traumatic - high risk of repeated anterior dislocations (80-90% recurrence rate); surgery often focuses on repair of bankart lesion (inferior GH ligament avulsed from labrum causing a tear or bony bankart lesion is anteroinferior labrum avulsion from the glenoid)

Internal impingement (be humeral head and the glenoid)

- most common form involves the underside of the supraspinatus and infraspinatus tendons pressing against the glenoid - signs and symptoms: pain in posterior shoulder during activity, loss of control and velocity with overhead throwers, restricted posterior joint play, restricted horizontal adduction, restricted internal rotation - strongly associated with glenohumeral internal rotation deficits (GIRD) and anterior instability (patients with GIRD have a tight posterior inferior GH ligament which results in superior translation of humeral head during GH elevation (overhead throwers and baseball pitchers prone to GIRD)) - conservative management: improve scapular control and reduce GIRD by stretching posterior structures - surgical treatment: stabilization to reduce migration of humeral head

Sternoclavicular (SC) joint sprain

- onset: acute - pain characteristics: limited to SC joint area - other symptoms: pressure on underlying neurovascular network that can cause paresthesia in the upper extremity; pressure on the trachea and esophagus impedes swallowing and breathing - mechanism: indirect force applied to the joint through the clavicle, such as FOOSH, or anteriorly or posteriorly directed forces exerted on the anterolateral or posterolateral shoulder - functional assessment: pain is increased with any shoulder motion that causes movement at the SC joint - inspection: dislocations are marked by displacement of the clavicular head anteriorly, superiorly, or posteriorly; first and second degree sprains may present with localized swelling over the joint; discoloration may not be present; the patient's neck may be tilted toward the involved joint; venous congestion of the involved arm, neck, and head may occur with posterior dislocation - palpation: obvious joint displacement may be felt, although this finding is often obscured by swelling; pain at the SC joint - joint and muscle function assessment: for first and second degree sprains, pain is elicited at any point after 90 degrees of elevation, after which the ligamentous structures are maximally taut; pain may be elicited during scapular protraction and retraction a. AROM: increased pain with flexion and abduction b. PROM: increased pain with flexion, abduction, and horizontal adduction c. MMT: isometric testing should not be painful - selective tissue tests: none - neurological screening: could be damage to neurological structures - vascular screening: could be damage to vascular structures - imaging techniques: a. anterior/posterior radiographs may be inconclusive; an oblique (serendipity) view will help visualize the displacementb. CT is the imaging of choice - differential diagnosis: proximal clavicle fracture, sternal fracture, first rib fracture, medial clavicle epiphyseal injury, pneumothorax - initial management: the immediate concern with SC dislocations is the potential compromise to the underlying structures from a posterior dislocation. Neurological and vascular examinations of the extremity and carotid artery on the involved side must be performed immediately. Any absent or diminished findings are considered a medical emergency. The involved arm is immobilized using the procedure described for clavicular fractures, and the athlete is immediately transported to an emergency medical facility. To avoid placing pressure on the structures posterior to the SC joint, the athlete must not be transported in a supine position. - treatment strategy: the initial management of SC joint dislocations is closed reduction with the patient sedated. An open reduction with concomitant joint stabilization is performed if the closed reduction fails. Early reduction is associated improved outcomes. Following a successful closed reduction, patients are managed with a period of immobilization in a figure-8 brace. Treatment of mild and moderate SC joint sprains typically involves palliative measures to decrease the signs and symptoms of inflammation and allow the injury to heal. Ice and sling immobilization are used as necessary to decrease the traction on the joint. ROM for the cervical spine and upper extremity are incorporated initially. As the pain and swelling at the joint decrease, strengthening of the surrounding musculature is initiated with a progressive return to functional activities. - comments: posterior SC dislocations are considered medical emergencies because of the potential threat to the underlying neurovascular structures, the esophagus, and the trachea; fractures of the medial one-third of the clavicle can produce a pseudoqislocation; the medial end of the clavicle is the last long bone epiphysis to close

Acromioclavicular (AC) joint sprain

- onset: acute - pain characteristics: superior anterior shoulder at the AC joint, anterolateral neck, and anterolateral deltoid - mechanism: falling on the point of the shoulder, landing on the AC joint, force applied longitudinally to the clavicle, such as FOOSH - functional assessment: increased pain with overhead motions - inspection: displacement of the clavicle may be obvious, step deformities indicate damage to the corococlavicular ligament - palpation: superior displacement of the clavicle that is reduced with manual pressure (piano key sign) - joint and muscle function assessment: a. AROM: pain with elevation of the humerus and during protraction and retraction of the scapula b. PROM: pain produced during elevation of the humerus owing to movement at the AC joint; increased pain with horizontal adduction c. MMT: decreased strength secondary to pain for all muscles having attachment on the acromion or clavicle - joint stability tests: a. stress tests: not applicable b. joint play: joint play movements reveal hypermobility of the AC joint - selective tissue tests: AC traction test, AC compression test - neurological screening: within normal limits - vascular screening: within normal limits - imaging techniques: a. AP radiograph to rule out associated clavicular or scapular fracture (primarily the coracoid process) and/or displacement between the acromion and clavicle b. stress radiographs are rarely required to identify AC joint dislocations - differential diagnosis: distal clavicle fracture, scapular fracture (coracoid), rotator cuff pathology, SLAP lesions - initial management: athletes displaying the signs and symptoms of an AC joint sprain require immobilization in a position that lessens the displacement between the clavicle and the acromial process. Initially, this may be achieved by using a foam pad with a hard shell held in place over the acromial process by a spica wrap and a sling supporting the weight of the arm. Athletes suffering from AC joint contusions, in addition to the standard modality protocol, need to have the joint protected with additional padding during activity. Such protection may be obtained by using a foam doughnut pad with a hard shell held in place by an elastic spica wrap or elastic tape. - treatment strategy: for patients with grade 1 and 2 AC sprains and those with chronic joint degeneration, conservative management is usually recommended. Conservative management for acute injuries consists of immobilization only as necessary for pain control and progressive increase in ROM and strengthening activities. Individuals with chronic joint pain are treated with symptomatic interventions such as non-steroidal anti-inflammatory medications and strengthening exercises focusing on scapular stability. Ultrasound - guided local corticosteroid injections can provide short-term relief of symptoms, but they do not alter the long-term progression of the condition. For patients with type 3 and higher AC joint injuries, surgical or conservative management is used, with the decision made on a case-by-case basis depending on the patient's desired type and level of activity. Conservative management consists of a short period of immobilization for pain control followed by early ROM and strengthening exercises. Surgical intervention for type 3 injuries may follow if symptoms persist, however, long-term outcomes are similar between those treated operatively and those treated non-operatively - comments: fractures of the distal clavicle may present with the clinical signs and symptoms of an acromioclavicular joint sprain

Superior labrum anterior to posterior (SLAP) lesions

- onset: acute or resulting from repetitive micro trauma - pain characteristics: pain in the superior portion of the shoulder; increased pain in position of 90 degrees of abduction and 90 degrees of external rotation; pain is typically not described at rest - other symptoms: patient may complain of clicking or catching - mechanism: landing on an outstretched arm, GH instability, overhead motions - risk factors: GH instability, posterior GH hypo mobility - functional assessment: complaints of inability to perform (ex. Decreased throwing velocity, decreased accuracy); increased pain with late cocking phase of throwing - inspection: forward shoulder posture, the scapula is protracted at rest - palpation: point tender at posterior GH joint, just inferior to acromion process - joint and muscle function assessment: A. AROM - limited internal rotation and horizontal adduction B. PROM - limited horizontal adduction, limited internal rotation C. MMT - pain with shoulder and elbow flexion - joint stability tests: A. Stress tests - not applicable B. Joint play - hypomobile posterior GH glide consistent with internal impingement - selective tissue tests: active compression (O'Brien) test, anterior slide test, compression-rotation (grind) test - neurological screening: within normal limits - vascular screening: within normal limits - imaging techniques: MR arthrogrophy, arthroscopy (anatomical variants make MR less accurate) - differential diagnosis: rotator cuff pathology, LHBT tendinopathy, internal impingement, acromioclavicular pathology, subacromial impingement, bankart lesion - treatment strategy: symptomatic lesions require surgical repair. Post-operative management of a patient with a SLAP lesion depends on whether the tear was debridement or repaired. Although cases of debridement can usually progress as tolerated, repairs progress more slowly. Most importantly, after a surgical repair, contraction of the biceps tendon and other traction forces fro the tendon placed on repair must be controlled for 6 to 8 weeks

Clavicular fractures

- onset: acute or traumatic - mechanism: fall onto shoulder (87%), blunt trauma to the clavicle (7%), FOOSH (6%) - directions of displacement: superior, inferior, posterior, overlap - components of a clavicular fracture examination: assess vital signs and performa neurovascular and lung examination (trouble breathing or swallowing; abnormal sensation, mechanical, radial pulse, and cap refill); palpate and observe for visible bulge (tenting skin), bone angulation, or displaced bone edges - initial management: immobilization using a sling or triangular bandage then transport for differential diagnosis; if a posterior fracture/dislocation is suspected, this is a medical emergency! Immediate referral is required with signs of neurovascular compromise, trouble breathing or swallowing, open wounds, or skin tenting - treatment strategy: When suspected, the arm must be immobilized to prevent movement of the fractured segments. T. The athlete is also transported to a physician for a definitive diagnosis. Non-displaced or minimally displaced fractures are treated with a sling, analgesics, and elbow ROM. Displacement fractures of the medial one third of the clavicle may require emergency surgery due to neurovascular compromise. Complete displacement fractures may opt to have plate fixation, or conservative management using a figure 8 brace or sling. In adults, most distal fractures are managed non-operatively. Surgical intervention may be indicated with extensive displacement. - comments: a sling and swath approach may be more comfortable for the athlete by taking the weight of the arm off of the involved clavicle. The use of figure-8 bandages for stabilization is discouraged as their use is associated with greater pain with no difference in functional outcome or appearance.

Scapular fractures

- onset: acute or traumatic - mechanism: secondary to GH dislocation/subluxation, avulsion of tendon or labrum - risk factors: incidence of scapular fractures is highest among players who wear relatively small shoulder pads - parts that could become fractured and how: body of scapula (avulsion), glenoid fossa (avulsion, labral avulsion, dislocation/subluxation), glenoid neck (avulsion, dislocation, subluxation), coracoid process (avulsion) - imaging techniques: If there is a GH dislocation, a radiograph is needed to rule out a secondary fracture to the glenoid or coracoid process - treatment strategy: to prevent motion, suspected scapular fractures are managed by immobilization of the arm on the affected side in a comfortable position, athlete is then transported for further medical evaluation - comments: although rare, scapular fractures have been reported in football players

Posterior glenohumeral dislocation

- onset: acute or traumatic - signs and symptoms: patient's arm adducted and internally rotated, coracoid process may be more prominent since the humeral head is moved posteriorly, humeral head may be palpable posteriorly, pain, swelling, unwillingness to move the arm - mechanism: arm flexed forward with a posteriorly directed force (often spontaneously reduces) damaging the middle glenohumeral ligament and posterior joint capsule - examination: look for arm posture, palpable gap, noticeable gap, or gross deformity - management: monitor the distal pulses, check for circulation in the finger tips, and perform a sensory screen; arm is fixed in the position it has assumed; reductions of GH dislocations should only be performed by those who are trained to do so (forced reduction of the humeral head may cause fracture to proximal humerus or glenoid)

Anterior Glenohumeral dislocations (most common)

- onset: acute or traumatic - signs and symptoms: patient's arm is slightly abducted and supported, acromion process is more prominent, flattened deltoid, pain, unwillingness to move, impaired sensation and motor function (axillary nerve involvement) - mechanism: external rotation with abduction (stresses/damages anterior and inferior ligaments) - examination: look for arm posture, palpable gap, noticeable gap, or gross deformity - management: monitor the distal pulses, check for circulation in the finger tips, and perform a sensory screen of the involved arm (absence of pulse indicates a medical emergency); arm is fixed in the position it has assumed; reductions of GH dislocations should only be performed by those who are trained to do so (forced reduction of the humeral head may cause fracture to proximal humerus or glenoid) however, reduction of anterior dislocations should occur as quickly as possible by qualified personnel to minimize damage and reduce the patient's pain and suffering (obtained by slightly abducting and internally rotating the arm while applying gentle longitudinal traction). - comments: can cause a bankart lesion (inferior GH ligament avulsed from labrum causing a tear) and hill-sachs lesion (bony defect to the posterior humeral head that occurs as humerus shears over anterior glenoid) to occur simultaneously

Inferior Glenohumeral dislocation

- onset: acute or traumatic (fairly uncommon) - mechanism: forced abduction with stress applied to inferior joint capsule (ex. Football, wrestling) that damages the inferior Glenohumeral ligament, superior glenohumeral ligament, and coracohumeral ligament - examination: look for arm posture, palpable gap, noticeable gap, or gross deformity - management: monitor the distal pulses, check for circulation in the finger tips, and perform a sensory screen; arm is fixed in the position it has assumed; reductions of GH dislocations should only be performed by those who are trained to do so (forced reduction of the humeral head may cause fracture to proximal humerus or glenoid)

Humeral fractures

- onset: acute or traumatic (most common in older adults) - mechanism: violent contraction of muscles that attach to humerus, may occur secondary to GH dislocation - parts that could become fractured and how: greater tuberosity (SIT avulsion), lesser tuberosity (subscapularis avulsion), surgical neck, mid shaft - examination findings: moderate to severe shoulder pain, holding effected arm adducted against their side, swelling and ecchymosis shortly after injury, gross deformities may occur (more typical with associated dislocation), focal tenderness over proximal or shaft of humerus - management: splint in position found using a moldable splint or vacuum splint, leave the wrist and fingers exposed to check circulation, transport

Scapular dyskinesis

- onset: gradual, identified during examination of other pathology - pain characteristics: localized over coracoid process, pec minor, superior and medial borders of the scapula, AC joint, posterolateral joint line or subacromial space, also possibly including upper trapezius and posterior cervical musculature (secondary to trap spasming) - risk factors: patient may describe a recent increase in overhead activity; may also be associated with other pathologies - functional assessment: poor shoulder function during overhead activity with an associated loss of strength, power, or endurance - inspection: thoracic kyphosis, cervical lordosis, and/or scoliosis; dominant side scapula may be positioned lower and more protracted than the non dominant arm at rest - palpation: may present with pain over coracoid process, pectoralis minor, superior and medial borders of scapula, posterolateral GH joint or subacromial space, upper trapezius, and posterior cervical region - joint and muscle function assessment: A. AROM - dysfunctional motion, position, or stability of the scapula observed during arm elevation or lowering B. PROM - GH internal rotation deficit (GIRD) may be present in overhead throwers C. MMT - decreased strength in lower and middle trapezius, serrates anterior; decrease in strength in rotator cuff secondary to the scapula failing to provide a stable base. scapular retraction test may be positive - joint stability tests: A. Stress tests - not applicable B. Joint play - joint play movements may reveal hypermobsility of the AC, SC, or GH joint - selective tissue tests: tests for rotator cuff impingement (subacromial or internal) or AC or labral pathology may be positive; scapular assistance test may be positive - neurological screening: within normal limits - vascular screening: symptoms resembling thoracic outlet syndrome may be reported - imaging techniques: within normal limits; typically, only suspicion of concurrent pathology warrants referral of these patients to a physician for imaging or assessment - differential diagnosis: cervical radiculopathy, supra scapular nerve syndrome, thoracic outlet syndrome, brachial plexus neuropathy/long thoracic nerve play - treatment strategy: management of scapular dyskinesis varies depending on the levels of activity, dysfunction, and associated pathology. Patients with severer scapulothoracic dysfunction may need to discontinue aggravating activities until more normal control is restored. For other patients, the activity level may be maintained during management. Improving scapular function is a component of any comprehensive shoulder rehabilitation or conditioning program. Because the majority of force produced during overhead throwing is produced by the lower extremity, strength, and stability of the legs, hips, and trunk must be assessed and established before addressing shoulder dysfunction. Conservative treatment that focuses on correcting scapular dysfunction is very often able to return competitive overhead athletes to their pre-injury level of performance within 4 months. Patients must avoid aggravating motions or activity during early rehabilitation. Early treatment may include local modalities and manual therapy for pain, inflammation, and any spasms in the upper trapezius, posterior cervical, or levator scapulae musculature. Rehabilitation is founded on improving scapular position by increasing flexibility and establishing conscious appreciation and control of scapular position. Positive scapular assistance and/or retraction tests also help identify specific control deficits that must be addressed.

Subacromial impingement (external)

- onset: insidious - pain characteristics: beneath the acromion and radiating to the lateral arm; pain during overhead movements in plane of scapula (may be relieved when applying inferior gliding force to humerus) - other symptoms: the patient may complain of popping and clicking, depending on involvement of bursa and rotator cuff musculature - mechanism: repetitive overhead motion impinging the rotator cuff muscles (especially the supraspinatus) and LHBT between the humeral head and coracoacromial arch - risk factors: rotator cuff weakness (atrophy of infraspinatus and supraspinatus); increased anterior laxity, irregularly shaped acromion (curved or hooked), subacriomial spurs, scapular dyskinesis - functional assessment: increased pain with overhead motions; may be coupled with compensatory scapulothoracic movement, with early and excessive scapular elevation and/or decreased posterior tilting during arm-raising maneuvers - inspection: the shoulder may be postured for comfort by holding the arm in slight abduction; a forward shoulder posture where the scapula rests in a protracted position and the humerus is internally rotated is frequently associated with impingement - palpation: tenderness exists beneath the acromion process, over the supraspinatus insertion at the greater tuberosity and over the bicipital groove - joint and muscle function assessment: a. AROM: active abduction in an arc of motion from about 70 - 120 degrees results in pain b. PROM: increased pain at the end-range of elevation; pectorals minor tightness is often associated with impingement c. MMT: pain and/or weakness with elevation in plane of scapula (empty can or full can test) and external rotation - joint stability tests: a. stress tests: a complete ligamentous and capsular screen is necessary to rule out GH and AC laxity b. joint play: GH hypermobsility and/or hypo mobility may be present; decreased thoracic spine mobility - selective tissue tests: the neer and Hawkins impingement tests are usually painful - neurological screening: within normal limits - vascular screening: within normal limits - imaging techniques: radiographs to rule out the primary cause of impingement, including a hooked acromion or osteophyte (little broken piece of bone) - differential diagnosis: labral tears, SLAP lesions, rotator cuff tendinopathy, subacromial bursitis, long head of biceps tendinopathy - comments: impingement may occur secondary to GH instability in younger patients; the degenerative response caused by rotator cuff impingement, if untreated, can lead to rotator cuff tears; temporary relief of symptoms associated with an injection of anesthetic into the subacromial space is indicative of impingement - conservative treatment: restore scapular kinematics, targeted stretching (pec minor), improve thoracic extension mobility, stretngthen rotator cuff - surgical treatment: aimed at altering shape of acromion

Rotator cuff tendinopathy

- onset: insidious or acute - pain characteristics: deep within the shoulder beneath the acromion process; pain usually radiates into the lateral arm - other symptoms: clicking during certain GH motions - mechanism: a. insidious: chronic impingement or degeneration of the rotator cuff tendons over time due to aging; a single traumatic episode could cause the final rupture of a weakened tendon b. acute: dynamic overloading of the tendon - risk factors: subacromial impingement, internal impingement, acromion changes, repetitive overhead motion, repetitive eccentric loading, scapular dyskinesis - functional assessment: pain during overhead motions; during elevation, the scapula may excessively protract, elevate, or anteriorly tip - inspection: in chronic cases, atrophy of the infraspinatus and/or spuraspinatus - palpation: tenderness in the subacromial space and at the insertion of the supraspinatus tendon into the greater tuberosity - joint and muscle function assessment: a. AROM: painful between 70 degrees and 120 degrees of elevation, especially in abduction b. PROM: decreased pain compared with AROM, except in positions of impingement c. MMT: pain and/or weakness with abduction, internal rotation, external rotation, and elevation in the plane of the scapula - joint stability tests: a. stress tests: tests to rule out GH and AC laxity and impingement b. joint play: joint play to assess for hyper- or hypo- mobility - selective tissue tests: drop arm test and impingement tests may be positive - neurological screening: within normal limits - vascular screening: within normal limits - imaging techniques: a. standard radiographic series consists of scapular plane AP, internal rotation, external rotation, and transscapular and axillary views to rule out rotator cuff tears and bony abnormalities. A subacromial space of less than 7 mm is indicative of a full thickness cuff tear b. MRI has a sensitivity of 0.95 and specificity of 0.95 in identifying rotator cuff tears, degeneration, and partial thickness tears c. MR arthrography, ultrasonography - differential diagnosis: AC joint degeneration, subacromial impingement, internal impingement, labral tear, long head of the biceps tendinopathy, capsulitis - comments: a history of rotator cuff tendinopathy often precedes a rotator cuff tear - treatment strategy: as with the management of different types of impingement, non-surgical approach to manage patients with rotator cuff tendinopathies emphasize an approach that addresses impairments that alter function and modification of activity as necessary. Strengthening must focus on the scapular musculature, the rotator cuff, and other shoulder muscles. (Strength of legs and trunk must also be analyzed). Surgery may be required for rotator cuff tears that limit participation. Based on the pathology, especially the size of any rotator cuff tear, the physician determines if surgery is done arthroscopically, with a mini-open technique. Post-operatively, rehabilitation is dictated by the type of surgery required. Although debridement of the subacromial space and rotator cuff can progress based on the patient's tolerance, rotator cuff repairs require careful use of active and resisted motions in the repaired tissues for a period of 6 to 8 weeks to allow healing to occur