1. Shoulder Pathologies and Physiotherapy Sharon Dekkers MSc MCSP
Hampshire Community Health Care
Shoulder Pathologies and Physiotherapy Sharon Dekkers MSc MCSP

2. Contents Anatomy Pathologies and Treatment Sources of referred pain
Exercises
Neural mobility exercises – sliders
Outcome measures

3. Anatomy – Shoulder joint complex
Glenohumeral joint
Acromioclavicular joint
Sternoclavicular joint
Scapulothoracic joint
Shoulder complex consists of 4 joints: GH, AC, SC, Scapulothoracic
Glenohumeral jt is a ball and socket jt formed between the humerus and scapula. The humeral head is much larger than the glenoid socket resulting in high mobility at the cost of less stability. The stability is provided by other structures such as the glenoid labrum, joint capsule, negative intra-articular pressure, muscles and ligaments.

4. Anatomy - Rotator Cuff Muscles
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis SS
Origin: medial 2/3 of supraspinous fossa
Insert: upper three facets of greater tuberosity
Stabilises the head in the glenoid.
Helps depress head of humerus. It works with deltoid during Abduction especially in range of 0-30 degrees
IFS
Origin: medial 2/3 infrapsinous fossa
Inserts: lateral 3 facets of grt tuberosity
Produces lat rot, helps depress head of humerus TM
Origin: lateral 2/3 scapula
Inserts: lower lat three facets grt tuberosity
Assists lat rot of GH joint with Infrapsinatus.
SScp
Origin: Medial 2/3 of subscapular border on costal surface.
Inserts: Lesser tuberosity, reinforces capsule.
Provides medial rot of joint.

5. Here you can see the anterior aspect of the rotator cuff
Here you can see the anterior aspect of the rotator cuff. Subscapularis attaches medial to the bicipital groove, on the lesser tuberosity. The long head of biceps runs from the supraglenoid tubercle through the joint making it intra-articular. In the bicipital groove it is held in place by the transverse humeral ligament formed with fibers from subscapularis. Suprapsinatus attaches on the superior facet of the greater tuberosity
You can also see the coraco-acromial ligament forming the coraco-acromial arch and also the acromioclavicular ligament between the acromion and the clavicle.

6. Anatomy - Rotator cuff posterior aspect
At the posterior aspect of the rotator cuff there are the insertions of IFS and TM which attach lateral to the bicipital groove, on the greater tuberosity.

7. Pathologies Impingement Syndrome Rotator cuff tear ACJ Labral lesions
LHB
TOS
Referred Pain

8. Impingement External Internal
External impingement (Sub-acromial Impingement Syndrome)
Primary
Bony abnormalities in the shape of the acromial arch
Bone spurs
Calcification
Secondary
Poor scapular stabilisation
Weakness of the rotator cuff
Muscular imbalance between deltoid and rotator cuff muscles.
Impingement Syndrome can be classified as external or internal:
External impingement can be either primary or secondary:
Primary: This is usually due to bony abnormalities in the shape of the acromial arch, degenerative changes such as bone spurs from the arch or calcification. These bony abnormalities impinge on the tendons.
Secondary
Usually due to poor scapular stabilisation which alters the physical position of the acromion, reduces the sub-acromial space and causes impingement on the tendons.
Other causes can include weakening of the rotator cuff tendons due to overuse or muscular imbalance between the deltoid muscle and rotator cuff muscles.

9. Impingement
Internal Impingement (Posterior Superior Glenoid Impingement)
Articular side of Supraspinatus becomes impinged between the greater tuberosity and the posterosuperior labrum.
Abduction and external rotation are affected.
Pain at the posterosuperior aspect of the shoulder
Internal impingement (Posterior Superior Glenoid Impingement)
Articular side of Supraspinatus becomes impinged between greater tuberosity and posterosuperior aspect of glenoid rim.
Abduction and external rotation are affected. The under side of the rotator cuff tendons are impinged against the glenoid labrum – this tends to cause pain at the back of the shoulder joint
Pain at the posterosuperior aspect of the shoulder
Condition may be seen in sports such as throwing or manual jobs such as painting with prolonged position of arm overhead in abduction and lateral rotation

10. Subacromial Impingement Syndrome (External)
Subacromial space
Space 9-10mm
Arm elevation – superior head displacement
Rotator Cuff muscles
Provide dynamic stability
Work with deltoid
Prevent superior translation of HH
RC – Deltoid balance
Subacromial space is formed by the coraco-acromial arch (constituting acromion, coraco-acromial ligament and coracoid process) above and the superior aspect of the humeral head below.
The space measures about 9-10 mm
As arm elevation occurs, there is a 3mm superior displacement at the centre of motion, whereby the RC tendons then activate
RC muscles
Provide dynamic stability to the GH joint.
RC tendons work with deltoid during elevation movements
preventing superior translation of humeral head
Deltoid acts to abduct arm but also creates superior translation of the head
RC muscles act to maintain the humeral head central within the glenoid and depress the head. When there is weakness of the RC, the deltoid is not counteracted and results in superior translation and impingement.

11. Sub-acromial space contents
Supraspinatus tendon
Long head biceps tendon
Subacromial bursa
Superior border of capsule

12. Causes of Impingement Instability/hypermobility
RC overuse or tendinopathy
Tight posterior GH capsule
Poor scapular muscle control
Poor Posture
Instability/hypermobility due to RC failure or weakness resulting in excessive translation of the humeral head. Excessive translation may lead to RC tendinopathy
RC overuse or tendinopathy which leads to thickening of the tendon and reduced sub-acromial space
Tight posterior GH capsule leads to superior and anterior translation of the humeral head which leads to reduced sub-acromial space and impingement.
Poor scapular muscle control or abnormal scapular rhythm positioning the scapula in an excessive downward rotated position, reducing acromial elevation and resulting in impingement. This may be due to poor serratus anterior or Lower trapezius activity and poor eccentric control as these are the main scapular upward rotators or may be due to shortening of pectoralis minor and levator scapulae.
Poor posture is often associated with FHP and increased thoracic kyphosis. This results in an anterior translation of the humeral head in relation to the trunk which is one of the factors to impingement

13. Causes of impingement Poor Tx spine extension – reduced GH elevation
Increased Tx kyphosis and FHP (forward head posture) will cause:
scapulae to abduct
resulting in lengthening of rhomboids and LFT
shortening of serratus anterior, latt dorsi, subscap – reduced scapular upward rotation
shortening of pect major and pect minor
pull the coracoid process downwards
bringing the acromion over the head of the humerus
causing a mechanical block to arm elevation
reduced subacromial space
Poor Tx spine extension (or Tx khyphosis ) can lead to poor GH elevation – limiting the last 15 degrees of elevation
An increased Tx kyphosis and FHP will cause
the scapulae to abduct
resulting in lengthening of rhomboids and lower fibres of trapezius
shortening of serratus anterior, latt dorsi, subscap. This leads to reduced upward rotation of the scapula during glenohumeral elevation.
There is also shortening of pect major and pect minor. Since Pect minor attaches to coracoid process it will tend to
pull the coracoid process downwards,
bringing the acromion over the head of the humerus
causing a mechanical block to arm elevation and
reduced subacromial space.

14. Impingement tests SIS Internal Impingement / PosteroSuperior
Hawkins Kennedy – pushes supraspinatus tendon / RC/ against coraco-acromial ligament
Neer’s Impingement test
Painful arc
Internal Impingement / PosteroSuperior
Shoulder Abd, LR induce posterior pain, relieved by humeral head relocation (AP glide of humeral head)
Practical demonstration
Hawkins and Kennedy
Neer
Painful arc
Internal impingement test
Pt supine, take arm into 90 abd and LR, If posterior pain (impingement of articular side CUFF tendon between the greater tuberosity and postsuperior glenoid rim) then relocate humeral head by AP glide, if pain decreases then +ve impingement.

15. Treatment Correct biomechanics of shoulder joint complex
Correct posture
Increase Tx mobility
Lengthen shortened muscles
Release tight posterior capsule or posterior cuff
Strengthen weaker muscles esp. RC and scapular upward rotators – SA and LFT
Correct biomechanics of shoulder joint complex
Correct posture
Increase Tx mobility by mobilisation of Tx and extension exercises
Lengthen shortened muscles particularly pectoralis minor; Pectoralis major
Release tight posterior capsule or posterior cuff
Strengthen weaker muscles esp. RC and scapular upward rotators – SA and LFT
Will show examples of treatment later on

16. RC Tear
Partial or Full
Overhead activity, trauma or recurrent impingement
If atraumatic - chronic diffuse pain more than 3 months
Common in over 40’s - Tendonosis, smoking, steroids, RA, Diabetes
Affects 7% of elderly
Unable to sleep on effected shoulder
Limited internal rotation, passively painful
A RC tear can be Partial or full
The RC can tear with repetitive overhead activity, trauma or recurrent impingement
If atraumatic, it develops as chronic diffuse pain for more than 3 months
Common in over 40’s as Tendonosis with PDF such as smoking, steroids, RA, Diabetes
Affects 7% of elderly
Unable to sleep on effected shoulder
Limited internal rotation, passively painful
studies have shown that approx 40% of individuals older than 60yrs had full thickness rotator cuff tears. However the relationship between pain, function and RC tear does not always correlate with painful shoulder dysfunction. Once the tendon tears, it compromises the functional stability of the GH joint leading to impingement.

17. RC Tests SS Full can Drop arm – eccentric control IFS
LR at 45deg MR at GHJ to minimize SS, post deltoid
LR lag sign, Drop sign (Stop) TM
Hornblower’s sign (LR in 90 scaption)
SbScap
Gerber Lift off / Belly press
Practical Demonstration
Supraspinatus
Full can test : 90 dg scaption with thumbs up, resist elevation
Drop arm from 90 scaption for eccentric control
Infraspinatus
IFS – arm by side, 45 MR at shoulder, resist LR – EMG showed most activation of IFS with minimized activity of posterior deltoid and SS
Lateral rot lag sign (with Supraspinatus): 20 abd in scapular plane, 90 elb flx and full LR, hold
Drop sign (Stop sign) : elb flx 90, abd 90 in scapular plane, full LR and hold.
Teres minor
Hornblower’s sign: 90dg scaption, elb 90 flx, resist LR
Subscapularis
Gerber lift off test : place hand behind back and 5 cm away from it and hold it there
If ROM limited test by MR in neutral – Gerber belly press test

18. ACJ Pain when lying on effected shoulder
Pain when reaching arm across body
Pain with passive or active arm adduction
Tender on palpation over ACJ
Scarf test / Cross body adduction
Pain when lying on effected shoulder
Pain when reaching arm across body
Pain with passive or active arm adduction
Tender on palpation over ACJ
Scarf test / Cross body adduction

19. Labral lesions Superior – SLAP Bankart lesion Causes FOOSH
Repetitive movements
Strong biceps contraction
Glenoid labrum injuries may be classified as superior - known as a SLAP lesion (superior labrum, anterior to posterior) and is a tear of the labral rim above the middle of the socket that runs from anterior to posterior region and may also involve the biceps long head tendon. This occurs most commonly with fall on outstretched hand.
Bankart labral lesion is a tear of the labral rim at an anteroinferior position, below the middle of the glenoid socket and also involves the inferior glenohumeral ligament. This creates instability and makes the shoulder prone to recurrent dislocations.
Causes
FOOSH
Tears of the glenoid labrum may often occur with other shoulder injuries, such as a dislocated shoulder.
Repetitive movements that create excessive motion at the glenohumeral joint such as throwing. Activities that require the biceps muscles to contract sharply against the labrum such as lifting heavy weight.
Bonding strength of labrum to glenoid increases with age and therefore labral tears are more likely in the younger population.
Symptoms
The symptoms of a labral tear may include a clicking or catching sensation in the shoulder during certain movements and/or a vague pain in the front or top of the shoulder.

20. Symptoms of glenoid labrum tears
Clicking or catching with shoulder movements
Vague pain at front or top of shoulder
Pain is made worse by overhead activities or when the arm is held behind the back.
Weakness and Instability in the shoulder.
Pain on resisted flexion of the biceps
Symptoms
The symptoms of a labral tear may include a clicking or catching sensation in the shoulder during certain movements
vague pain in the front or top of the shoulder.
Pain is made worse by overhead activities or when the arm is held behind the back.
Weakness and Instability are present in the shoulder.
Pain on resisted flexion of the biceps

21. Labral SLAP tests O’Brien Active Compression Test Crank test
Pt stdg, flexion 90°, adduction 15° with elbow extended
Full MR so thumb pointing down
Resist flexion
Pt laterally rotates arm so thumb pointing up
Positive test = Pain or painful clicking elicited with thumb down and decreased or eliminated with thumb up
Crank test
Shoulder elevated to 160° in the scapular plane
A gentle axial load is applied through glenohumeral joint with one hand, while other hand does IR and ER
Positive test = pain, catching, or clicking in the shoulder
Practical Demonstration
O’Brien Active Compression Test
Pt stdg, flexion 90°, adduction 15° with elbow extended
Full MR so thumb pointing down
Resist flexion
Pt laterally rotates arm so thumb pointing up
Positive test = Pain or painful clicking elicited with thumb down and decreased or eliminated with thumb up
In test position biceps tendon is displaced medially and inferiorly, tensioning the bicipital labral complex, creating shear forces in the glenoid and labrum resulting in deep, anterior pain and clicking. This position is similar to the cross body adduction test for ACJ, however the site of pain is different with ACJ dysfunction being be more superior and less deep and due to the greater tuberosity being locked under the acromion and moved out of the way by supination.
Crank test
Shoulder elevated to 160° in the scapular plane
A gentle axial load is applied through glenohumeral joint with one hand, while other hand does IR and ER
Positive test = pain, catching, or clicking in the shoulder

22. Long Head Biceps
Yergason’s test Elbow flexed 90. Resist supination of forearm. Positive test if tenderness over bicipital groove
Speeds test Resist forward flexion of extended and supinated arm from 0 – 60 dg flexion
Practical Demonstration
Yergason’s test Elbow flexed 90. Resist supination of forearm. Positive test if tenderness over bicipital groove
Speeds test Resist forward flexion of extended and supinated arm from 0 – 60 dg flexion

23. Thoracic Outlet Syndrome
Abnormal compression of the neurovascular bundle by bony, ligamentous or muscular structures at thoracic outlet
Neural symptoms:
Paraesthesia esp C8T1 dermatomal distribution
Pain in upper limb and hand
Numbness
Muscle weakness and atrophy of hand muscles
Difficulty with fine motor control of hand
Abnormal compression of the neurovascular bundle by bony, ligamentous or muscular structures at thoracic outlet
Neural symptoms:
Parasthesia along the inside forearm and the palm (C8, T1 dermatome)
Pain in the arm and hand
Numbness
Muscle weakness and atrophy of the hand flexors, thenar and intrinsics
Difficulty with fine motor tasks of the hand

24. Thoracic Outlet Syndrome
Vascular symptoms:
Deep pain at neck and shoulder, worse at night
Feeling of heaviness in arm or hand
Fatigue in arms and hands
Swelling of hand
Bluish discoloration
Superficial vein distention in hand
Deep pain at neck and shoulder, worse at night
Feeling of heaviness in arm or hand
Fatigue in arms and hands
Swelling of hand
Bluish discoloration
Superficial vein distention in hand

25. TOS Interscalene triangle Costoclavicular triangle Subcoracoid space
The brachial plexus trunks and subclavian vessels are subject to compression or irritation as they course through 3 narrow passageways from the base of the neck toward the axilla and the proximal arm.
The most important of these passageways is the
interscalene triangle,formed by the anterior scalene muscle anteriorly, the middle scalene muscle posteriorly, and the medial surface of the first rib inferiorly. Structures such as fibrous bands or cervical ribs may constrict this triangle. Anterior scalene tightness causing Compression of the interscalene space between the anterior and middle scalene muscles may be probably due to nerve root irritation, spondylosis or facet joint inflammation leading to muscle spasm.
The second passageway is the costoclavicular triangle, which is bordered anteriorly by the middle third of the clavicle, posteromedially by the first rib, and posterolaterally by the upper border of the scapula. Costoclavicular approximation resulting in Compression in the space between the clavicle, the first rib and the muscular and ligamentous structures in the area may be probably due postural deficiencies or carrying heavy objects.
The last passageway is the subcoracoid space beneath the coracoid process just deep to the pectoralis minor tendon. Pectoralis minor tightness resulting in Compression beneath the tendon of the pectoralis minor under the coracoid process-may result from incorrect posture or frequent sitting at desk jobs

26. TOS Tests Allen’s test Adson’s test Allen’s test Sitting
Locate the radial pulse
Neck rotation toward the tested arm
Neck extension
PT extends the arm
Deep inspiration with hold
A positive test is indicated by a disappearance of the pulse.
Allen’s test
Shoulder horizontal extension and lateral rotation
Palpate radial pulse
Neck rotation away from the tested arm
Positive if radial pulse disappears
Practical demonstration
Adson’s
Sitting
locate the radial pulse
neck rotation toward the tested arm
neck extension
PT extends the arm
Deep inspiration with hold
A positive test is indicated by a disappearance of the pulse.
Allen’s test
shoulder horizontal extension and lateral rotation
Palpate radial pulse
Neck rotation away from the tested arm
positive if radial pulse disappears

27. Referred Pain : Cervical

28. Referred Pain: Gastro-Intestinal
Liver : R shoulder
Gall bladder: R shoulder and R scapula
Diaphragm : unilateral / bilateral shoulder pain
Spleen: L shoulder + upper 1/3 arm
Aortic Aneurysm: L scapula
Cardiac: L shoulder + Scapula
Post Laparoscopy: uni / bilateral shoulder pain
Liver : R shoulder
Gall bladder: R shoulder and R scapula
Diaphragm : unilateral / bilateral shoulder pain
Spleen: L shoulder + upper 1/3 arm
Aortic Aneurysm: L scapula
Cardiac: L shoulder + Scapula
Post Laparoscopy: uni / bilateral shoulder pain
Liver, Gall bladder and duodenum all can irritate the diagphragm which is innervated by C3, C4 C5.
C3 C4 spinal cord levels also receive sensory input via the supraclavicular nerves. So when pain is elicited from abdominal organs it may be felt as referred pain in the shoulder.
Laparascopy involves the injection of CO2 gas in order to better view the organs. This results in irritation of the diaphragm and the phrenic nerve, resulting in referred pain.

29. Referred Pain: Pancoast Tumour
Tumour of apex of lung
Invade chest wall structures such as
Lymphatics
Lower roots of brachial plexus (esp. C8, T1)
Intercostal nerves
Sympathetic chain and Stellate ganglion
Adjacent ribs
Initial symptom is pain in the shoulder and medial aspect of scapula
Referred pain to C8, T1, T2 dermatomes
Horner’s syndrome later develops
Pt supports arm to relieve neural tension
Hand muscles later develop atrophy
Pancoast tumour originates at the apex of the lung. It mainly extends into the chest wall structures rather than the underlying lung tissue.
Invade chest wall structures such as
Lymphatics
Lower roots of brachial plexus (esp. C8, T1)
Intercostal nerves
Sympathetic chain and Stellate ganglion
Adjacent ribs
The initial symptom is pain in the shoulder and medial part of the scapula
Referred pain to C8, T1, T2 dermatomes
Horner’s syndrome later develops – drooping eyelid, reduction in size of pupil
Patient supports arm to relieve neural tension
Hand muscles later develop atrophy

30. Exercises Scaption instead of Abduction
Better joint congruence
Reduced tensile forces on ligaments
Optimal sub-acromial space and clearance
Optimal alignment of RC muscles
Increased proprioceptive feedback
Increased activation of scapula upward rotators and RC muscles
Exercises for RC with minimization of deltoid and Upper Fibres Trapezius activity
Scaption instead of Abduction
Scaption is flexion of the GHJ in the plane of the scapula
Better joint congruence
Increased proprioceptive feedback
Reduced tensile forces on ligaments at superior and anterior aspects of shoulder
Optimal sub-acromial space and clearance of greater tuberosity
Optimal alignment of RC muscles
Optimal activation of scapula upward rotators and RC muscles
Exercises for RC with minimization of deltoid activity and UFT
Due to the imbalance often present between RC and deltoid resulting in superior migration of the humeral head, it is important when giving exercises to try to eliminate activation of deltoid.
Also important to eliminate UFT activation due to their frequent overactivity resulting in elevation of the scapula and reduction of sub acromial space.

31. Exercises RC Supraspinatus Infraspinatus / Teres minor Subscapularis
Full can in scaption +/- wt
Empty can in scaption <90dg
Infraspinatus / Teres minor
LR in varying degrees of abduction
Subscapularis
MR in varying degrees of abduction
Diagonal exercise
Dynamic hug
Push up plus
Practical Demonstration
Supraspinatus
Full can in scaption +/- wt
Empty can in scaption
Infraspinatus / Teres minor
LR in varying degrees of abduction
Subscapularis
MR in varying degrees of abduction
Diagonal exercise (replacing sword)
Dynamic hug
Push up plus

32. Scapular exercises Side lying flexion +/- wt
Side lying lateral rotation +/- wt
LFT – prone arms overhead
MFT – prone 90 abd with LR
UFT – prone arms by side
Scapular setting progression in prone:
Short lever arm, lateral rotation (wrist lift)
Short lever arm, medial rotation (elbow lift)
Short lever arm lift
Long lever arm lift
Long lever arm lift with wt
Stability exs – active wall slide with towel, 4 point, and ball press ups
Practical demonstration
Side lying flexion +/- wt. In side lying, the UFT activity is minimised, allowing better recruitment of LFT and MFT during GH elevation.
Side lying lateral rotation +/- wt. Limits posterior deltoid
LFT – prone arms overhead
MFT – prone 90 abd with LR
UFT – prone arms by side
Scapular setting progression in prone:
Short lever arm, lateral rotation (wrist lift)
Short lever arm, medial rotation (elbow lift)
Short lever arm lift
Long lever arm lift
Long lever arm lift with wt
Stability exs – active wall slide with towel, 4 point, and ball press ups
Scapular setting exercises: initially the force is low to ensure proper fibre recruitment. The contraction shoulder be sustained and repeated so as to improve endurance properties. Once proper recruitment is achieved, load can be increased provided that the postural position of scapula is controlled.

33. Exercises Serratus Anterior Knee Push up plus Push up plus
Seated press up
Forward punch with TB attached behind
Scaption with wt
Dynamic hug
Practical demonstration
Serratus Anterior
Knee Push up plus – on hands and knees
Push up plus – on hands and toes
Seated press up – also may be used on w/c or a/c
Forward punch with TB attached behind – arms at waist height
Scaption with wt
Dynamic hug

34. Posterior capsule tightness
STM of soft tissues at posterior shoulder
Medial rotation stretch (Sleeper’s stretch)
Horizontal adduction stretch
AP glide in neutral / medial rotation
AP axial glide in horizontal adduction
Corner stretch for pectoralis minor
Doorway stretch for pectoralis major
Practical Demonstration
STM of soft tissues at posterior shoulder
Medial rotation stretch (Sleeper’s stretch)
Horizontal adduction stretch
AP glide in neutral / medial rotation
AP axial glide in horizontal adduction
Wall stretch for pectoralis minor
Doorway stretch for pectoralis major

35. Neural mobility exercises
Median nerve
Radial nerve
Ulnar nerve
Median nerve originates form C5 - T1 nerve roots of the Brachial Plexus
Passes deep to bicipital aponeurosis and enters forearm between 2 heads of pronator teres.
Passes down deep to FDS on FDP and at 5 cms above flexor retinaculum becomes more superficial as it passes through carpal tunnel to palm of hand.
The Ulnar Nerve
Originates from C7 – T1 and
At elbow – it lies in the ulnar groove on the post aspect medial epicondyle.
Enters forearm between 2 heads FCU
Passes in front of the flexor retinaculum on lat side of the pisiform lying medial to the artery
Radial Nerve
C6-TI
Passes obliquely across the back of the humerus into the Radial groove
At front of lateral epicondyle it divides into superficial & deep.
Superficial Branch
Descends from in front of lat side lat epicondyle
At 7 cm above the wrist, winds round the lateral side of the radius, divides into 5 dorsal digital nerves.
Deep branch Posterior Interosseous Nerve
Front of lateral epicondyle.
Enters forearm, between 2 heads of supinator muscle.
Practical Demonstration of neural mobility exercises for
Median
Radial
ulnar

36. Outcome measures - SPADI
Activity
Difficulty
Pain
1. Washing your hair?
2. Washing your back?
3. Putting on an undershirt or pullover sweater?
4. Putting on a shirt that buttons down the front?
5. Putting on your pants?
6. Placing an object on a high shelf?
7. Carrying a heavy object of 10 pounds?
8. Removing something from your back pocket?
Disability scale: How much difficulty do you have….
0 = no difficulty 10 = unable to do NA = not applicable

37. DASH (Disabilities Arm Shoulder Hand)
SPADI and DASH have been found to acceptable construct validity and responsiveness when tested on patients with adhesive capsulitis.

38. Outcome measures – Simple shoulder test