Commonest cause of pain around the shoulder, it is a
disorder of the rotator cuff which sometimes
referred as rotator cuff syndrome.
Rotator cuff muscles :- Supraspinatus, Infraspinatus,
Subscapularis and Teres minor.
:- Fall or direct impact trauma
:- Acute overload incident or develop gradually from
By excessive force (lifting a very heavy object with the
arm extended / trying to catch a heavy object as it falls).
Typical RCI occurs to a middle aged person or older has
an experienced problem of shoulder.
Also occurs in injuries or condition such as arthritis,
tendonitis or bursitis affect the shoulder joint.
Pain and loss of mobility can result.
Weak shoulder muscle.
Repetitive stress on the shoulder
1) Shoulder pain, usually when moving the shoulder or
sleeping on it.
2) Tenderness in shoulder
3) weakness in shoulder
4) Not being able to move the shoulder as much as
normal (decrease ROM)
5) Soreness in the shoulder
6) Impossible to raise the arm or move it away from
6. CLINICAL FEATURES
Complain of pain with overhead activity such as
throwing, swimming, overhead shots in racquet sports,
activities undertaken <90° of abduction are usually pain
Associated symptoms of instability such as recurrent
subluxation or episodes of dead arm.
Depends on the stage of disorder, age of the patient
and vigorous of heading response.
7. 3 PATTERNS
1) Subacute tendinitis (Vascular congestion, edema and
hemorrhage leads painful arc syndrome)
2) Chronic tendinitis (recurrent shoulder pain due to
tendinitis and fibrosis)
3) Cuff disruption (Recurrent pain, weakness and loss of
It occurs due to repetitive compression or rubbing of the
tendon (mainly supraspinatus)
When the arm is abducted the conjoint tendon slides
under the coracromial arch.
If the arm is held persistently in abduction and then
moved to and fro in IR and ER (as in cleaning a window,
painting a wall or polishing a flat surface.
Rotator cuff may be compressed and irritated as it
comes in contact with the anterior edge of the acromion
process and the taut coracoacromial ligament. This
attitude has been called the Impingement position,
(Abd, slight flx, IR)
9. OTHER FACTORS
Repetitive Impingement :-
o Swelling of cuff
o Osteophytes on the anterior edge of the
o Formation of bony edges
o Thickening of the AC joint
10. OTHER FACTORS
Friction :- Localized edema and swelling
3 variation of acromial morphology
Type I :- Flat
Type II :- Curved
Type III :- Hooked acromion
Prolonged or repetitive impingement (older age)
Minute tears can developed these may be followed by
scarring , fibrocartilaginous, metaplasia or
calcification in tendon
11. ON EXAMINATION
Physical examination:- Therapist assist the full ROM of
shoulder yet patient is unable to complete the same
movements using their own strength.
MRI scan:- To determine torn
Impingement:- Aim is to elicit pain while moving the
greater tuberosity under the acromion.
12. ON EXAMINATION
Hawkins kennedy test :- The shoulder is placed in
90° of forward flexion and then forcibly internally
Resisted movement :- Empty can position (90° of
abduction, 30°of horizontal flexion and full internal
rotation) . This test may indicate supraspinatus
abnormalities. Repeat with a retracted scapulae.
13. CLINICAL MANAGEMENT
Anti- inflammatory drugs (ibuprofen)
Steroid injection in the bursa, shoulder joint, around the
tendons to reduce inflammation, pain and increase
mobility of shoulder joint.
If it is not successful, surgery may needed such as
arthroplasty of shoulder, suturing, tendon repair etc.
19. POST OPERATIVE
1) Acute phase
Tissue healing:- Rest
:- Short term mobilization
Decrease pain & inflammation:-NSAID,
:- cold compression
Re-establish ROM:- Pendulum exercise
:- Manual capsular stretch
:- Cross fiber massage
:- T -pulleys, ropes or bars
To decrease muscle atrophy :- Isometric exercise with
arm below 90° of abduction and 90° of flexion.
Scapular control:- Closed chain weight shifts with hands
on table and shoulder flexed less than 60° and abducted
less than 45°.
Maintain fitness in rest of kinetic chain
o Aerobic exercise :- Running, bicycling or stepping
o Anaerobic :- Agility drills
o Elbow and wrist :- Strengthening by Isometric
exercises or rubber tubing
o Flexibility exercise
Criteria for movement out of the acute phase
o Minimal pain, Kinetic chain integration, manual
muscle strength, progression of tissue healing,
PROM at 66%-75% of opposite side
2) Recovery phase
:- Active assisted motion above 90° of Abduction with hand
:- AROM in IR and ER with scapula stabilized
:- Scapular PNF patterns.
:- closed chain exercise at 90° of flexion, 90° abduction,
scapular retraction/ protraction and elevation / depression
:- Modified push –ups
:- Ball catch and push exercise
:- Dips ; clock , low row ,lawn mower
Upper extremity strength and strength balance
:- GH PNF patterns
:-Closed chain exercise at 90° of flexion then 90° of
:- Forearm curls ; isolated rotator cuff exercise
:- light bench presses
Normal shoulder Arthokinematics
:- RoM with arm 90° of abduction
:- Proprioceptive sensory feedback
:- Open chain exercises – mild plyometric exercise
Normal kinetic chain and force generation
:- Normalization of all inflexibilities throughout kinetic
:-Normal agonist –antagonist force couples in leg using
squats, plyometric depth jumps.
:- Trunk rotation exercise with medicine ball or tubing.
:- Integrated exercise with leg and trunk stabilization,
rotation , diagonal patterns from hip to shoulder and
medicine ball throw.
:- Rotator cuff strength 4⁺/5 or higher.
:- Normal kinetic function.
3) Functional phase
Power and endurance in UE
:- Diagonal and multiplanar motions with rubber tubing,
light weights, small medicine balls and isokinetic
:-Plyometrics – wall push – ups, corner push – ups,
weighted ball throws and tubing
Increase multiple plane neuromuscular control
:-Kinetic chain to generate and funnel the proper forces
to and through the shoulder.
Clinical orthopaedic rehab by S. BRENT Brontzman
and Kevin E.WILK (second edition)
Clinical sports medicine by Peter Brukner and Karim
Khan ( third edition)
Physical Medicine and Rehabilitation by Walter R.
Belmaire et al. Rehabilitation Management of
Rotator Cuff Injuries in the Master Athelete
(American college of sports medicine, 2019)