- Hawkins’ test forward flexes the arm to 90°and
applies maximum internal rotation to the flexed
elbow. If one supplies downward pressure at the
elbow while the patient resists, the sensitivity of
the exam increases (Hawkins and Kennedy, 1980;
Valadie et al, 2000).
RADIOGRAPHIC EXAMINATION
- Standard radiographs include an anteroposteior
(AP), axillary, and supraspinatus outlet view. These
views will allow you to determine if there is degen-
erative joint disease in the AC or glenohumeral
joints, spurring from the acromion or calcification
within the tendon (calcific tendonitis). Chronic rota-
tor cuff tears will often result in superior humeral
head migration secondary to atrophy of the lower
rotator cuff. A true scapular AP view will allow
better examination of the glenoid and internal and
external rotation view will allow better assessment
of the humeral head for defects or impression frac-
tures. - Special radiographs are indicated in certain condi-
tions. A supraspinatus outlet view is often obtained to
evaluate the morphology of the acromion in rotator
cuff or impingement syndrome. A West Point view is
helpful in evaluating the anterior glenoid for bony
deficiency in cases of instability. - MRI is an excellent tool for determining rotator cuff
pathology, but is often overused and/or obtained too
soon. - Certain signal characteristics are indicative of full
tears versus partial tears versus AC arthritis. A mag-
netic resonance imaging (MRI) can determine labral
pathology (Bankart lesions, or SLAP tears), bursitis,
acromial morphology, and articular cartilage condi-
tion. More details about MRI for upper extremity
injuries can be found in chapter 43. - An MRI does not need to be obtained immediately if
the patient has full ROM and only complains of pain
and weakness. These patients can be started on the
nonoperative treatment described below and the vast
majority will improve. An MRI can be obtained after
the next visit if the patient’s symptoms have not
resolved with therapy.
NONOPERATIVE TREATMENT
- Rotator cuff strengthening is essential for recovery
and many patients improve after surgical intervention
because they finally commit themselves to the reha-
bilitation.- The focus of rehabilitation should be to reduce
inflammation (usually bursal), restore motion, and
strengthen muscles to help stabilize the scapula and
humerus. Therapists will start with anti-inflammatory
modalities, work on ROM and begin periscapular
strengthening to stabilize the scapula (Jobe and
Moynes, 1982; Wilk and Arrigo, 1993). - Nonsteroidal anti-inflammatory drugs (NSAIDs) are
usually helpful to help decrease the bursitis and
reduce the pain. They are not curative in themselves,
but decrease pain so the patient can do therapy. In rare
instances, the pain is severe enough for a short course
of narcotics.
•A subacromial injection can be performed as a diag-
nostic test or as part of the treatment plan. When the
Neer sign is positive, an injection is made into the
subacromial space using a local anesthetic. The
patient is retested after 3–5 min and the Neer test is
positive if the pain is relieved. Many physicians who
are certain of their diagnosis will proceed with a ther-
apeutic injection of 2–3 cc of an injectable corticos-
teroid at the same time. Others will inject a second
time if the initial injection relieves the patient’s symp-
toms. - If there is a diagnostic dilemma between whether the
AC joint is the cause of pain or the bursa, injections
can be performed in one location and then the second
to determine the source. The subacromial injection
should be done first because with AC pathology—the
capsule is often disrupted and an AC injection is likely
to go into the bursa as well. The reader is referred to
chapter 72 on injections for more information. - Once the pain is reduced and the ROM restored, more
aggressive strengthening exercises are instituted.
Internal and external rotation exercises using rubber
tubing or resistance bands are very useful, and the
patient progresses to heavier tubing, as they get
stronger. Supine or lateral decubitus exercises with
small weights are also started at this time. - Core strengthening exercises to help stabilize the
scapula are also instituted. These exercises are very
important and often neglected. Simple exercises such
as squeezing the shoulder blades together or scapular
rows are often effective. Progress is monitored by
observing normal scapulothoracic motion with eleva-
tion. If scapular winging is severe or fails to improve
with treatment, further workup for other etiologies
such as trapezius or long thoracic nerve palsy should
occur. - Deltoid strengthening, to include isolated training of
all three parts of the deltoid. - Strengthening of the supraspinatus is not instituted
immediately because it will aggravate symptoms.
Supraspinatus strengthening should be started when
- The focus of rehabilitation should be to reduce
270 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE