The Shoulder Joint
The shoulder joint is one of the most complex joints in the human body. When we refer to the shoulder we usually mean the glenohumeral joint, which is formed by the head of the humerus and the glenoid fossa of the scapula. We shouldn’t forget that for proper shoulder function, coordinated movement of several other joints is necessary. These are:
- The sternoclavicular (SC) joint: Clavicle and Sternum
- The acromioclavicular (AC) joint: Acromion and Sternum
- The scapulothoracic joint: Not a true anatomic joint. Depends on the integrity of the abovementioned joints.
Epidemiology (Luime et al. 2004)
The literature describes the incidence of shoulder pain to be between 0,9 – 2,5%. (31-35y: 0,9%; 42-46y: 2,5%; 56-60y: 1,1%; 70-74y: 1,6%)Shoulder pain is very common with a point prevalence of 6,9 to 26% in the general population. The 1-month prevalence for shoulder pain is described at 18,5-31%, 1-year prevalence ranges from 4,7 – 46,7%, with a lifetime prevalence of 6,7-66,7%. This makes shoulder pain the third most common musculoskeletal complaint after low back and neck pain with cuff-related problems as the most common shoulder injury. In general, the prevalence of shoulder pain is higher in women and increases with age.
Shoulder pain generally has an unfavorable prognosis with only 30% of patients recovering after six weeks and 54% after six months (Kuijpers et al. 2006). Van der Windt et al. (1996) report a median duration of complaints of 21 weeks. Luime et al. (2004) report that 50-70% of all patients still have complaints after six months, and 40-50% still experience complaints after one year. The recurrence of shoulder pain was reported to be 20-50%.
Verhagen et al. (2014) describe that the following factors are associated with a negative prognosis for recovery:
- High pain score at baseline
- Long duration of complaints
- Insidious onset of complaints
- Concomitant neck pain
- Impairments in activities of daily living (ADLs)
- Psychological factors without further specification
- Repetitive movements are described as a factor in work-related shoulder pain
Next to the general red flags, specific red flags in the shoulder joint can be:
Region-specific red flags
- Tumors in the brain, breast, lung (most often Pancoast tumors), liver, and spine
- Infections: History of surgery, open wound, swelling, redness, heat fever
- Avascular necrosis: Trauma, Cancer, steroid use/abuse (Gruson et al. 2009)
In general, all tissues irritating the diaphragm can create visceral referred pain in the shoulder
- Heart disease/angina: Often sharp stabbing pain in the left shoulder, arm, lateral neck, increasing with exercise; risk factors include: Age>40y, hypertension, diabetes, smoker, high cholesterol, etc.
- Respiratory system: Look for impairments in breathing, shortness of breath, dizziness, etc.
- Liver cirrhosis (right shoulder): excessive alcohol, family history of liver disease, history of Hepatitis B or C, obesity, jaundice, swollen legs, ankles, abdomen (ascites), feet
- Spleen (abscess or rupture can produce left ACJ pain): Kehr Sign –> Pain increases in supine with feet elevated (Söyüncü et al. 2012)
- Gall bladder/Cholecystitis (right scapula): Increase in pain after a fatty meal, fever, nausea, vomiting
- Peptic ulcer (deep dull pain felt mid-thoracic/scapula): Increases after meals, long-term use of NSAIDs
Apart from red flags, shoulder pain has to be distinguished from referred pain from the cervical facet joints in the neck, cervical myelopathy, or cervical radicular syndrome. So if concomitant neck pain is present, further examination of the neck region should be done in order to rule out the above-mentioned pathologies. In order to learn more about these differential diagnoses, we would like to refer you to the “Further reading” section at the bottom of this unit.
Shoulder pain can be roughly divided into three main groups:
- Shoulder pain with limited passive range of motion (PROM) and shoulder pain directly related to the glenohumeral joint (Frozen Shoulder or Osteoarthritis)
- Shoulder pain without limited PROM, but a painful abduction component (painful arc), usually indicating Subacromial Pain Syndrome (including rotator cuff pathology with or without tendinopathy of the biceps and bursitis)
- Other shoulder complaints without limited PROM and without a painful arc (Shoulder Instability, AC or SC Joint Pathology)
In order to divide your patient’s shoulder pain into one of those 3 categories, a basic assessment should be performed. It’s best to start with an Active Range of Motion Assessment:
Standard values for the range of motion in different directions are as follows:
As described in the basic categorization above, it is important to look for a painful arc.
AROM assessment is then typically followed by Passive Range of Motion Assessment (PROM) which you can watch by a click on the following video:
During PROM assessment, it’s important to compare the range of motion as well as the end-feel of the affected shoulder with the unaffected side. After AROM and PROM assessment you should be able to categorize the patient into one of the three basic categories for shoulder pain.
Stenvers et al. (1977) have come up with 5 different quick tests in order to assess the mobility of the shoulder girdle.
Specific Pathologies in the Shoulder
There are several pathologies that are commonly seen in the shoulder area. For more information, click on the respective pathology (content will be added in the near future):
- Rotator Cuff Tear
- Full-Thickness Rotator Cuff Tears
- Scapular Dyskinesis
- Subacromial Pain Syndrome
- Internal Shoulder Impingement
- Shoulder Instability
- SLAP (Superior Labrum Tear from Anterior to Posterior) lesion/Biceps Tendinopathy
- Acromioclavicular Joint Pathology
- Frozen Shoulder
Cook CE, Wilhelm M, Cook AE, Petrosino C, Isaacs R. Clinical tests for screening and diagnosis of cervical spine myelopathy: a systematic review. Journal of Manipulative & Physiological Therapeutics. 2011 Oct 1;34(8):539-46.
Kuijpers T, van der Windt DA, Boeke AJ, Twisk JW, Vergouwe Y, Bouter LM, van der Heijden GJ. Clinical prediction rules for the prognosis of shoulder pain in general practice. Pain. 2006 Feb 1;120(3):276-85.
Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, Verhaar JA. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scandinavian journal of rheumatology. 2004 Mar 1;33(2):73-81.
Söyüncü S, Bektaş F, Cete Y. Traditional Kehr’s sign: Left shoulder pain related to splenic abscess. Ulusal travma ve acil cerrahi dergisi= Turkish journal of trauma & emergency surgery: TJTES. 2012 Jan;18(1):87-8.
Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003 Jan 1;28(1):52-62.
- Aurelio09/12/22Orthopedic Physiotherapy of the Spine ORTHOPEDIC PHYSIOTERAPY OF THE SPINE
Fantastic course! simple to follow and extremely helpful in assessing and treating spinal related issues. Furthermore, it is possible to immediately apply the knowledge acquired in the clinic. A must for us physiotherapists.Aurelio09/12/22Orthopedic Physiotherapy of the Upper and Lower Extremities ORTHOPEDIC PHYSIOTERAPY OF THE UPPER AND LOWER EXTREMITIES
Great course! It allows you to make objective assessments with order and clarity. As a result, it is possible to set up effective and efficient treatments.
I also found the sections on the epidemiology and course of the diseases very useful, in order to educate patients and obtain greater compliance with the treatment. Super recommended!!DUNCAN10/01/21Orthopedic Physiotherapy of the Upper and Lower Extremities GREAT COURSE
Great course, lots of information, the instruction videos are really helpful.
- DOUWE WILLAERT28/12/20Orthopedic Physiotherapy of the Upper and Lower Extremities i would recommend this course to everyone.
if i may give one suggestion that is maybe hard to implement. but i sometimes struggle with explaining things in patient language. so maybe add some frequent asked questions / mechanisms from patients and how to explain it simple or with a metaphore ?
Thanks again for all your work putted in to this course <3JEROEN VAN ZANTEN20/10/20Orthopedic Physiotherapy of the Upper and Lower Extremities I LOVE IT
This course really helps the starting physio. It gives you more convidence. The first year out of school i was really not convident and after this ( relative cheap) course, it got better! Thanks a lot physiotutors! I also got motivation to start studying manual therapy, as i know now, that there is way more to learn.WOUTER13/09/20Orthopedic Physiotherapy of the Upper and Lower Extremities FUN AND EASY TO IMPLEMENT IN THE CLINICAL PRACTISE
Took my time to learn and enjoy form this course!
Would definitely recommend this to other physiotherapist who work in the first-line care.
- ANTONIUS SMOOK22/08/20Orthopedic Physiotherapy of the Upper and Lower Extremities GREAT COURSE
They go, from the basic assessment to the lower and upper limb, step by step with scientific reasoning. It’s a very usefull course to improve your clinical reasoning in practice.JASMIN KONJIC07/07/20Orthopedic Physiotherapy of the Upper and Lower Extremities REALLY REALLY GREAT!
Everything is extremely well-researched and carefully structured! My only complaint, or actually just a hope for their future courses is that more things should to be structured as bullet points. It can sometimes hard to remember facts from a big block of text. Other than that, amazing. Thanks for your great work guys, it’s been a big help!AVIV27/05/20Orthopedic Physiotherapy of the Upper and Lower Extremities Great course, very nice and clean, full attention to details, great job boys!
- Thomas20/03/20Orthopedic Physiotherapy of the Upper and Lower Extremities STARKES KONZEPT!
Starkes Konzept wissenschaftlich untermauert für die Haupt-Diagnosen der Extremitäten. Sehr übersichtliches Design. Gute Möglichkeit das Lernen einzuteilen. Fortbildung der Zukunft. Nur zu empfehlen. Freue mich auf die nächsten Kurse!Marc07/01/20Orthopedic Physiotherapy of the Upper and Lower Extremities LEERZAAM
Goede opbouw en uitleg per onderdeel.JUDITH06/01/20Orthopedic Physiotherapy of the Upper and Lower Extremities My compliments for this online course! I’m feeling all up to date now! I can see why it is highly accredited with the KNGF. Other than expected I quite enjoyed taking the course! Good structure ,good balance between text en videos and content en quiz. For me the assessment assignments worked great to lock the knowledge in! Quizzes are sufficiantly challenging and force/ motivate to really study the contents, think about it and listen to the questions carefully!
Great video footage of tests and exercises! Great links to articles! All very useful for dailey practice (even in osteopathy ;)) and immediately applicable! Should contribute to communication with other health care specialists e.g. when it comes to clinical reasoning for requesting further medical examination e.g. immaging. I already recommended the course to several colleagues!
One point of attention: I got the feeling that the short quizzes at the end of each unit didn’t always mach the unit’s content or plainly state differently (e.g. Type of SLAP lesions).
- AARON03/01/20Orthopedic Physiotherapy of the Upper and Lower Extremities PERFECT INFORMATION
Much of it was fresh rehearsal including some new insights! Would recommend.DIMITRY22/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities THE FUTURE OF PHYSIOTHERAPY
I think this course should be done by all physiotherapists! The evidence based principle should be adopted by every physiotherapist, this course is a great way to learn how to apply tests, but also background information, advice for patients and some rehabilitation. I believe this kind of course is the future of physiotherapy and is very suitable for everyone.Marijke13/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities BEDANKT!
Uitstekende manier van leren.
- LIEKE11/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities PERFECT
The course was very interesting Learned a lot!JORN08/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities ZEER LEERZAAM!
Zeer leerzame cursus, welke zeker de moeite en tijd waard is!
Gaat goed stapsgewijs dieper in op de stof.
Zorg er wel voor dat je engels up-to-date is.MATAN03/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities GREAT COURSE
Super cursus!! Overzichtelijk en up to date.
- Willem01/12/19Orthopedic Physiotherapy of the Upper and Lower Extremities EXCELLENT COURSE!
A course of the highest quality. It adresses a plethora of conditions both theoreticaly and practically. Everything is well laid out and substatiated with current research. Its fun to take and challenging. If you spend the nescessary time on this course youre sure to learn a lot.
Theres allways room for some pointers so
Andreas you should stop staring so aggresivly during the examinations, its scaring me. Just lay off the steroids for a while and youll mellow out soon enough, theyre other ways to get swole bro.
Kai youve been blasting me with research citations during the whole course. my head is about to explode. Youve been luring me to the dark side of science but i know this knowledge has been paid for in missed sleep and coffee. The bags under your eyes attest to this.
Just joking, you guys are heroes to everyone enrolled in the physiotherapy eduction and therapists alike. ill be buying all of your courses as will the rest of my team.HYEOK17/11/19Orthopedic Physiotherapy of the Upper and Lower Extremities GREAT COURSE FOR NOT ONLY FIRST YEAR PHYSIOS BUT ALSO EXPERIENCED PHYSIOS.
I’ve been working in this field for 10 years and still learn from many resources such as books, youtube channels, essays and so on. And this course is awesome because it’s time efficacy and broad perspective of information in each chapter from basic anatomy, pathophysiology, to treatment. After taking this course for 5 months, I able to give more clear, updated information about each patient’s conditions and course of the current problem.
I hope you guys make another course for the spine . I wil take it!Rik24/10/19Orthopedic Physiotherapy of the Upper and Lower Extremities This course showed me some new insights that I can use in my own practice.
The course is easy to follow in your own time.
I really enjoyed it!
- M.J. Post08/09/19Orthopedic Physiotherapy of the Upper and Lower Extremities As I said, great course. When you take this course, you’re being pushed into improving your assessment skillset.Vadym Grytsenko29/07/19GREAT ILLUSTRATION OF WHAT ONLINE EDUCATION SHOULD BE! The great course with absolutely new approache to study information online!
Content is extremely useful in daily physiotherapy routine and all the material is based upon scientific researches. I did rehearse the screening and assessment process.
Great illustration of what online education should be!Jerry06/06/19GREAT! It was an excellent course! Took me 33 hours and 26 minutes to complete. I liked the cases a lot and the statistics gave me a totally new point of view to assess different tests. This course will make me a better physiotherapist. Thank you!
- Francisco Javier31/05/19THE UNIVERSITY OF THE FUTURE Awesome Course!!!, honestly it´s the University of future, you will learn all the commmon pathologies of the body with just 1 click: epidemiology, prognostic factors, course, asessment and treatment, everything from a scientific point of view. Well structured, easy to read, fast navegation, high quality videos. You will be able to answer your patient how long the complaints will last base on the last evidence with proper numbers, giving a fair prognosis which will help you to keep them motivate to the therapy and be patients and constant. There is no a day when I dont use it in the practice to consult a specific test or the sensibility of this one. Even you get you acreditation points, a bunch of them actually in comparison with other courses that you will never use in your daily routine. 100% advisable!!!
Curso Magnifico!!!, honestamente, es la universidad del futuro, aprenderá todas las patologías comunes del cuerpo con un solo clic: epidemiología, factores pronósticos, curso, evaluación y tratamiento, todo desde un punto de vista científico. Bien estructurado, fácil de leer, navegación rápida, videos de alta calidad. Podrás responder a tu paciente cuánto tiempo durarán sus molestias basado en la última evidencia con los números adecuados, lo que les dará un pronóstico justo que los ayudará a mantenerlos motivados para la terapia y ser pacientes y constantes. No hay un día en el que no lo use en la práctica para consultar una test específico o la sensibilidad de este. Incluso se obtienen puntos de acreditación, un monton ellos en comparación con otros cursos que luego nunca usas en su rutina diaria. 100% recomendable!!Nathan28/05/19Orthopedic Physiotherapy of the Upper and Lower Extremities A great course for new grads! I have found this course to be very well put together. Firstly the formatting is very user friendly – it’s easy to work through but also very to easy to navigate to specific sections to use as a reference resource. As always with these guys the videos are very high quality. The attention to detail with academic references is also spot on. You can be assured that the info is evidence based. Overall, highly recommended.Stijn14/02/19GREAT COURSE I thinks this course is great, I find the framework it teaches you very useful in assessing my patients. I like how the different pathologies are very clearly explained from epidemiology to pathophysiology to diagnostics to treatment, all evidence based. The Physiotutors-style videos used to explain the subject matter are really useful for studying too. Finally, the assingments at the end of the chapters are a great way to test and practice your knowledge on the subject you just studied.
- Remy29/05/22Orthopedic Physiotherapy of the Upper and Lower Extremities Great course; gives you a good foundation to build upon. As for potential improvements; maybe include a bit more articles that are freely available for people that don’t have access to the scientific database.Rick10/01/22Orthopedic Physiotherapy of the Upper and Lower Extremities USEFUL AND CLEAR
The course consists of easily understandable bite sized lessons. This way it was easy to spend a little time every day to work on this course. All information is easily to find and it is not too much information to remember. It really helped me as a starting physio to get more structure and confidence in my intakes and testing procedures.
Sometimes there are some grammatical or spelling mistakes, but those don’t bother me. Sometimes it would have been nice to maybe have had a bit more information on treatments though.
All-in-all a great course that I would recommend, especially for starting physio’s!GHADEER02/09/21Orthopedic Physiotherapy of the Upper and Lower Extremities EXCELLENT BUT MISSING PRINTED VERSION
Such an informative course, covers everything a physio requires! Would be better if they offered a printed material! Had a hard time with reviewing due to availability solely on e version.