Shoulder Derangement with

an Underlying Dysfunction
from a MDT Perspective
Keeley Garrou
Regis University

Objectives
Audience will be able to differentiate

derangement and dysfunction in terms of

Mechanical Diagnosis and Therapy by end of
presentation
Audience will be able to list possible treatment
interventions for rotator cuff tendinopathy by
end of presentation
Audience will be able to apply the literature
and physiology of tissue remodeling to physical
therapy exercise by the end of presentation

Meet Sammie

15 year old female

softball player
Plays 1st base
Has been playing
softball since she was
six
Cannot remember the
last time she has had
time off of playing
softball
Right shoulder pain

Many people, both

young and old suffer

from shoulder pain
from no traumatic
mechanism of injury
At any point in time,
6.9-26% of people
have shoulder pain
Lifetime prevalence
is from 6.7-66.7%2

Mechanical Diagnosis and Therapy

Comprehensive and

logical step-by-step
process that
classifies patient
conditions by level of
pain or limitation
Three steps10
that results from
Assessment
certain movement or
Treatment
10
positions
Prevention

Mechanical Diagnosis and Therapy

Assessment
Algorithm that leads to

classification of disorders
which is based the
relationship between
historical pain behavior as
well as the pain response
to repeated test
movements, positions and
activities during the
assessment process10

Mechanical Diagnosis and Therapy

Assessment Continued
The assessment is a systematic progression of
applied forces and responses to separate
patients into defined subgroups to guide
treatment
Two of the basic classifications for the
extremities are
Derangement: Anatomical disruption or
displacement within the motion segment
Dysfunction: End-range stress of shortened
structures (scarring, fibrosis, n.root adherence)10

Mechanical Diagnosis and Therapy

Treatment -

most treatment
is with repeated
motion, with a
progression of
unloading,
clinician
overpressure,
mobilization and
manipulation as
needed10

MDT emphasizes

patient education
and involvement so
that the patient can
manage
themselves without
having to come in
and be dependent
on the clinician10
Goals to reduce
pain quickly and
restore function
and independence10

Purpose
The purpose of this case report is to illustrate

and describe the assessment and treatment

for shoulder pain using the Mechanical
Diagnosis and Therapy method

Initial Evaluation
History:
Pt came in with the complaint

of right shoulder pain

Pain started in March after a
double softball practice
Currently, shoulder aches all
the time; heavy lifting
increases pain
Pain is not that bad when
playing softball but it aches
afterward

Pt has practice once per week

with tournaments
approximately every other
weekend playing up to five
games
Pt received MRI negative for
tears but did show swelling in
her shoulder
Pt was prescribed an antiinflammatory; she reports she
does not take them as
prescribed
She often takes Advil or Tylenol
for pain
Pt reported no other comorbidities

Initial Evaluation
Examination
Initial AROMs
Abduction

147

Flexion

145

Internal
rotation arm
behind back

Thumb to T8
with pain

Internal
rotation

30

External
rotation

112 with pain

Measured AROM with

large goniometer
Measured IR behind
back with palpation of
spinous process
to measure ROM

limitations which then

translate into
functional limitations
In order to reference
improvement
PROM in supine: No pain

Initial Evaluation
Special Tests

Cervical spine AROM

Spurlings Test
ULNT
Active compression
AC Distraction
AC sheer
Sulcus Test
Load and Shift
Neers

No symptom provocation
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative

Anterior instability and impingement are common in baseball and have been

linked to decreased in IR and concurrent increases in ER,7 therefore wanted to test

for impingement and instability

Initial Evaluation
Strength Testing (MMT)
Abduction

Could not test secondary to

pain

External Rotation
5/5 with pain

Scapular dyskinesia
Initial Treatment
Attempted mobilization with

movement with shoulder

abduction to increase ROM
with reduced pain4

Results patient could not

tolerate secondary to pain

Kinesiotape to reduce shoulder

pain

Results patient reported reduced

pain with movement and
resistance

Evidence6
Thelen M, Dauber J, Stoneman P.
The clinical efficacy of kinesio tape
for shoulder pain: a randomized,
double-blinded, clinical trial.
Investigated efficacy of kinesio
tape when applied to college
students diagnosed with rotator
cuff tendonitis/impingement
Conclusion: Kinesio tape may
assist clinicians in improving painfree AROM immediately after
taping

The Patient-Specific Functional

Scale
Activity

Score

Throw soft ball

Do a push up

Play Basketball

Average Score

6.3

Primary Functional Goal: Sammie will

score 8.8/10 or greater on The PatientSpecific Functional Scale indicating

improvement in overall function
Minimum detectable change for average
score = 25

Visit 2
Beginning ROMs: R shoulder Abd 124 with pain, Flex 152
Used MDT for assessment and treatment: Repeated shoulder

extension and repeated shoulder extension with clinician

overpressure
Instructed patient to extend her arm, palm facing up, as high as

she can
Patient was instructed to repeat 10 times
Rechecked abduction less pain but still painful
Patient repeated 4 sets of shoulder extension until pain had
reduced to a constant
Then, patient extended shoulder and clinician gave overpressure
Continued extension with overpressure for 4 sets of 10 repeating it
until she had no pain with abduction

Post treatment: Abd 163 with no pain

Visit 2
The abolishment of symptoms lead to the MDT

diagnosis of reducible derangement because the

symptoms were decreased with repeated movement
(extension) and then abolished with therapeutic
loading strategies (extension with overpressure) ,
which was accompanied by improvements in the
mechanical presentation (ROM)3
Began therapeutic exercise to improve muscle
performance
Home Exercise Program Patient instructed to perform
10 repeated extensions every 2-3 hours, particularly
before and after softball games and when she felt pain

Visit 3
Assessment: Sammie

presents with no
shoulder pain and no
significant loss of ROM
allowing for increased
function with daily
activities. Sammie
requires further
monitoring and
strengthening to return
to prior level of
scholastic athletics.

Plan:

Continue/alter/progres
s extension principles;
assess response to
softball practice,
continue therapeutic
exercises for
strengthening for
return to sport

As treatment
continued . . .
Sammie reported that

Hypothesis: Sammie

presents with a reducible

shoulder no longer hurt
derangement with an
during the day but would
underlying soft tissue
still hurt after softball
dysfunction
practice
Reasoning: Sammie had
Repeated extension
pain consistently with
always reduced pain with
resisted abduction at 90
movement however there
and external rotation at 0
was an underlying pain
but with no other
when given resistance
positions. Pain would
with external rotation at
subside once the force was
0 and abduction at 90
removed

Tendinopathy
Tendon injury can occur from acute trauma or

repetitive loading from overuse

Of all injury related physician visits, almost
7% are from overuse injuries
The most common site for an overuse injury is
at the osteotendinous junction
Tendons are predisposed to hypoxic tendon
degeneration from the low blood supply to the
tendon insertion8

Treatments for
Tendinopathy

Most common and

effective treatments8
Goal of treatment
Reduce pain
Return to function

Relative rest of

affected area
Stretching
Ice
Analgesics

Visit 8: ASTYM
ASTYM is a stimulation of the bodys

healing response, which results in the

remodeling/resorption of scar tissue and
the regeneration of degenerated
tendons.9
ASTYM restarts the bodys inflammation
process which can then start
healing/tissue remodeling
PT certified in ASTYM performed an
assessment and treatment on Sammies
right upper extremity and noted
increased tissue texture in right anterior
shoulder, AC joint and long head of biceps
This finding helped confirm the
hypothesis that Sammie had an
underlying soft tissue dysfunction in the
shoulder with scarring and fibrosis

Therapeutic Exercise to Promote

Tissue Remodeling
Eccentric External Rotation
With green TheraTube in
doorway with towel under
elbow
Fast external rotation with
slow eccentric internal
rotation
4 sets of 15 repetitions
Scaption
At 45 angle lifting to

approximately 90
3 lb weights
2 sets of 15 repetitions with
slow eccentric lowering

Bicep Curls
Bicep curl palms up, lower

with palms down

3 lb weight
3 sets of 15 repetitions with
slow eccentric lowering
This will help remodel the
tissue to resolve the
dysfunction
Mechanotherapy load is used
therapeutically to stimulate
tissue repair and remodeling
in tendon, muscle, cartilage
and bone1

Visit 10 Last Available

Visit
The Patient-Specific Functional Scale average score

= 8.3
Abduction AROM 175 with no pain
Sammie reported minimal pain with softball games
No joint mobility restrictions
Continues to have pain with resisted external
rotation demonstrating tissue dysfunction requiring
further treatment for tissue remodeling
Sammie will benefit from up to 4 more treatments
for ASTYM for tissue remodeling and to progress
her to an independent home exercise program

Summary of Case
Sammie presented with

shoulder pain and

decreased ROM
ASTYM assessment
Pain was reduced and
and treatment
ROM increased with
confirmed dysfunction
repeated shoulder
extension reducing the
Dysfunction was
derangement
treated by continued
Sammie continued to have
ASTYM and repeated
residual pain with resisted
eccentric loading to
movement consistent with
soft tissue dysfunction
remodel tissue and

resolve dysfunction

Limitations
Did not record PROM

measurements
Did not record initial
strength
measurements for all
shoulder motions
Physical Therapist
Student not
certified/proficient in
Mechanical Diagnosis
and Therapy method

Not generalizable to

all patients
Did not perform intrarater reliability
Some missing data
collection
Patient not yet
discharged

Were you listening?

What MDT diagnosies am I demonstrating?
What is the theory behind ASTYM?
What type of exercises are best for tissue

remodeling?

Questions?

References
1. Khan K, Scott A. Mechanotherapy: how physical therapists' prescription of exercise promotes

tissue repair. British Journal of Sports Medicine [serial online]. April 2009;43(4):247-252.
2. Luime J, Koes B, Heridriksen I, et al. Prevalence and incidence of shoulder pain in the general
population; a systematic review. Scandinavian Journal of Rheumatology [serial online]. March
2004;33(2):73-81.
3. McKenzie R, May S. The human extremities mechanical diagnosis and therapy. New Zealand:
Spinal Publications Ltd; 2000.
4. Mulligan BR. Manual Therapy 'Nags'. 'Snags', -MWM'. etc. 4'"ed. Wellington, New Zealand: Plane
View Series Ltd, 1999.
5. Stratford P, Gill C, Westaway M, Binkley J. Assessing disability and change on individual patients: a
report of a patient specific scale measure. Physiotherapy Canada. 1995;47:258-263.
6. Thelen M, Dauber J, Stoneman P. The clinical efficacy of kinesio tape for shoulder pain: a
randomized, double-blinded, clinical trial. Journal of Orthopaedic & Sports Physical Therapy [serial
online]. July 2008;38(7):389-395.
7. Thomas S, Swanik K, Swanik C, Huxel K, Kelly IV J. Change in Glenohumeral Rotation and Scapular
Position After Competitive High School Baseball. Journal of Sport Rehabilitation [serial online]. May
2010;19(2):125-135.
8. Wilson J, Best T. Common overuse tendon problems: a review and recommendations for treatment.
American Family Physician [serial online]. September 2005;72(5):811.
9. www.astym.com
10. www.mckenziemdt.org