Examining outcomes of returning to work with restrictions in a patient with bilateral partial rotator

cuff pathology: a worker’s compensation case.

Kyle Murison, SPT

Suzanne Ryer, PT

Carroll University

Waukesha, WI

Spring 2014

ABSTRACT:

Background and Purpose: Rotator cuff injuries have been well researched over the years, especially in regards to full thickness tears. There is a gap in the literature in determining the effectiveness of returning to work in a patient with bilateral partial thickness rotator cuff tears. The purpose of this study is to examine the impact that return to work with restrictions has on outcomes of a repetitive upper extremity reaching job in a patient with bilateral rotator cuff pathology and a workers compensation claim.

Case Description: The patient was a 59 year old male with an acute, bilateral shoulder injury at work. His job demands required repetitive work overhead, reaching, lifting overhead and push/pulling. His current restrictions consisted of no lift/push/pull >20 pounds and no overhead lifting. Primary impairments included ROM, strength, pain, and joint play. The interventions included anti-inflammatory strategies, PROM, joint mobilizations, AAOM, AROM, and therapeutic exercises. The patient presented with severe increases in pain and disability, decreased ROM, and decreased strength throughout bilateral shoulders.

Outcomes: Following a 6-week physical therapy intervention outcomes were measured using ROM, strength and Shoulder Pain and Disability Index (SPADI). Improvements were noted in AROM including R GH flexion by 46 degrees, abduction by 50 degrees, external rotation by 22 degrees, and internal rotation by 18 degrees. Statistically significant declines were noted in L UE flexion by 33 degrees, abduction by 19 degrees, and external rotation by 10 degrees. PROM of the R GH improved in flexion by 50 degrees, ABD by 57 degrees, and external rotation by 24 degrees. PROM of L GH declined in IR by 17 degrees. Strength of the R UE shoulder internal rotation improved by 3 full grades and improved 2 full grades in flexion, abduction and external rotation. There were no statistically significant changes found in L UE strength. The total SPADI score improved on R shoulder by 23.1% and L shoulder declined by 1.5%.

Discussion: The findings of this case report suggest that work restrictions and bilateral involvement may be negative prognostic factors in Workers’ Compensation cases if the appropriate measures are not taken. Repetitive tasks are often not assessed and therefore are not addressed in patients work restrictions even though repetitive reaching is a main contributing factor to rotator cuff impingement 20. Overall, patient’s work restrictions and assessment are crucial in proper healing if return to work is necessary 18. Keywords: Bilateral Rotator Cuff Pathology, Physical Therapy, Worker’s Compensation

Background and Purpose

Rotator cuff injuries have been well researched over the years, especially in regards to full

thickness tears. However, the research on partial thickness tears has been lacking. The treatment costs

of shoulder dysfunction in the United States totaled $7 billion in 20001. Rotator cuff pathologies

amounted to 10% of all those shoulder dysfunctions1. Bilateral shoulder injuries are unlikely in either the

acute or chronic nature. A study conducted by Yamaguchi et al looked at the morphological

characteristics and prevalence of rotator cuff tears in patients with unilateral shoulder pain. They found

that out of 588 patients, 177 had a bilateral tear (either partial or full thickness) 8. When the symptoms

are bilateral in nature, an in-depth examination is warranted to determine if there is a nerve palsy or

neurological component that played a role in the injury. As with all musculoskeletal conditions, it is

important to understand the patient as a whole and identify each impairment and contributing factor of

the disorder. There are many factors that can play a role in the development of rotator cuff pathology.

The contributing factors to rotator cuff pathology are classified into intrinsic and extrinsic

categories. Intrinsic factors are considered to be metabolic and vascular changes that ultimately lead to

degeneration tears/intratendonous lesions which result from shearing forces5. Other factors include

anterior instability of the glenohumeral joint, posterior glenohumeral capsular contracture, decreased

humeral retroversion, tension overload, poor throwing mechanics, and scapular muscle imbalance3.

Extrinsic causes may be due to subacromial impingement, shoulder instability, internal impingement, an

acute traumatic injury, or repetitive microtrauma secondary to overhead activities3,5. It is common that

more than one of these contributing factors are responsible for the partial thickness tear in each case5.

Treatment strategies and outcomes are based on the previously listed contributing factors and each

patient should be addressed in an individualistic approach.

There is limited research on patient’s potential for recovery comparing the patients who have

workers compensation claims to those who do not with partially torn rotator cuffs. In a review of

workers compensation treatment of rotator cuff pathologies, the conclusion was that patients had

poorer outcomes as compared to patients who were non-worker compensation, and this included both

pre and post-operative treatments16. Patients with active worker compensation claims consistently

experienced greater pain, lower quality of life, and have poorer function, while the tear size and muscle

involvement did not appear to be associated with compensation status16.

Patients with work-related injuries have restrictions set to the amount of activity that the

patient can perform during a work day. Most restrictions are based on the amount of weight that the

patient is able to lift, push/pull, carry, etc. Rotator cuff injuries occur from either over-use or an acute

tear. Setting work restrictions and/or determining when a patient is ready for work duties is a difficult

task. The repetitive nature of the task is often left out when determining the restrictions. To determine

the appropriate work restrictions for the patient, it is first important to identify the patient’s job

function. There are three categories of frequencies (occasional, frequent, and constant) of force

exertion per activities such as lifting, carrying, pushing, pulling, or any other physical activity as defined

by the Dictionary of Occupational Titles. The frequencies are determine based on the percentage of time

devoted to the task per workday: occasional (0-33%), frequent (34-66%), and constant (67-100%)15.

According to Keith L Blankenship, the next step is to have the patient perform a one-rep max of the task

that they will be performing. This weight is then multiplied by a given percentage depending on the

previously stated frequency in which they will be performing these duties at work: Occasional (60% of

the one-rep max), Frequent (20% of the one-rep max), and Constant (10% of the one-rep max) 15.

One study performed by van Rijn et al looked at the association between type of work and the

variables of the work that were associated with higher prevalence of rotator cuff injuries11. The

occurrence of subacromial impingement syndrome is associate with the following physical risk factors:

force requirements of >10% of MVC, lifting >20 kg >10 times/day, high hand-force >1 hour/day,

repetitive movements of the shoulder, hand and wrist >2hours/day, using vibrating tools >2 hours/day,

upper arm elevation >90 degrees, working with the hand above shoulder level >1 hour/day, upper-arm

flexion >45 degrees for >15% of time and duty cycle of forceful exertions >9% of the time, and upper-

arm flexion >45 degrees for >15 % of the time11.

A cross-sectional study done by Svendsen et al looked to determine whether work performed

with arms in an elevated position is associated with alterations in the rotator cuff tendons. The subjects

consisted of 137 male patients, between 40 and 50 years of age, and had the occupation of machinist,

mechanic, or painter. Shoulder pain was not an inclusion criteria. The subjects underwent an MRI which

concluded that there was a relationship between elevated arm position >90 degrees and alterations in

the supraspinatus tendon12.

Another study by Frost et al looked at the relation of shoulder loads in repetitive work and the

risk of shoulder tendonitis. The study consisted of 1961 subjects who were placed through multiple

different tasks with varying loads. The symptoms and clinical criteria defined the shoulder tendonitis

and the results showed the tendonitis was higher among exposed workers. They concluded that the

workers with repetitive tasks had increased risk of shoulder tendinitis secondary to the force

requirements of the lifting14.

However, in an article looking at the determinants of outcomes in treatment of rotator cuff

disease utilized 136 patients with impingement syndrome and performed conservative treatment to see

which findings at initial presentation correlated with final outcome. They concluded the variables that

did not seem to be predictive of final outcome of non-operative treatment of rotator cuff pathology

include age, gender, dominance, acute or chronic onset, recreational or occupational demands2.

The purpose of this study is to examine the impact that return to work with restrictions has on

overall outcomes of a repetitive upper extremity reaching job in a patient with bilateral rotator cuff

pathology and a workers compensation claim.

Case Description

The patient presented as a 59 year old Caucasian male who suffered an acute, bilateral shoulder

injury while at work on 12/6/2013. His pain began while he was lifting and pulling a 70 pound bar mill

roll of metal blocks when he felt a sharp pain in both his left and right shoulders (R>L). He was reaching

to his right with outstretched arms, pulling towards his right hip. The motion at his left upper extremity

(LUE) included GH horizontal adduction/internal rotation, elbow flexion and scapular protraction. The

motion at his right upper extremity (R UE) included GH internal rotation/extension, elbow flexion, and

scapular retraction. He was referred to therapy by an urgent care physician for physical therapy.

He was employed as a mechanic in a metal shop and had worked in this profession for over 35

years. His job demands required repetitive work overhead, arms away from the body, lifting 70 pounds

floor to waist, lifting 45# waist to overhead, and push/pulling. Prior to the injury, the patient was

working at regular duty. However, he had pain in both shoulders over the last few years and has had a

history of cortisone injections in both shoulders. The patient was on work restrictions consisting of <20#

lifting floor to waist, no push/pull >20#, and no overhead lifting.

The patient had a past medical history including C5-C6 anterocervical discectomy with fusion,

hypertension, osteoarthritis, and low back pain. He remained on light duty consisting of less than twenty

pounds lifting/pushing/pulling and no overhead lifting. His medication list included Aleve (two tabs, two

times per day or as needed). His pain was described as constant aching with occasional sharp/burning

pain. The pain was rated on the right GH as 4/10 at rest and 8/10 at the worst, and the left GH was rated

3/10 at rest and 6/10 at the worst. Aggravating factors included overhead activities, sleeping, and

working with outstretched arms. Alleviating factors included rest.

Clinical Impression

There is little research on prognosis and ability to return to full work functions in a patient with

bilateral shoulder involvement. Since pain was his greatest limiting factor, a thorough differential

diagnosis was performed to pinpoint the pain source and contributing factors associated with the injury.

This was completed using palpation, special tests, and other strategies to identify the source of pain.

Examination

Upon initial evaluation, the patient completed the Shoulder Pain and Disability Index (SPADI)

which has been shown to be a reliable and valid outcome measure of current shoulder pain and

disability (reliability coefficient of ICC ≥0.89, internal consistency is high with Cronbach α typically

exceeding 0.90, and demonstrates good construct validity compared to other shoulder questionnaires) 9.

He scored on the right upper extremity a 37/50 on the pain scale, a 42/80 on the disability scale, and a

total of 79/130 for the total SPADI score. He scored on the left upper extremity a 32/50 on the pain

scale, a 41/80 on the disability scale, and a total of 73/130 for the total SPADI score. The minimal

detectable change (90% confidence interval) is 8 points.

Observation and Palpation

The patient demonstrated bilateral rounded shoulders, flexed low cervical spine, extended

upper cervical spine, bilateral scapular winging and upward rotation. He presented with guarded

movement of bilateral upper extremity during all transitional movements and scapulothoracic

dyskinesia as per examination during bilateral GH elevation in standing. He was tender to palpate over

bilateral supraspinatus, upper trapezius, middle trapezius, levator scapulae, pectoralis major, pectoralis

minor, subscapularis, and right biceps longhead.

Range of Motion

Bilateral shoulder ROM was assessed using a standard goniometer aligned as described in

Norkin and White10. Intra-tester reliability has been shown to range from 0.87 to 0.99 for all shoulder

motions and 0.78 to 0.90 for cervical motions10. A statistically significant change in ROM is considered to

be between 5 degrees (1 standard deviation) to 10 degrees (2 standard deviations) 10. Trunk and cervical

ROM were assessed via observation and no significant impairments were noted. The patient was limited

in AROM and PROM in B UE flexion, abduction, extension, internal rotation and external rotation. Refer

to table 1 for AROM. Refer to Table 2 for PROM. All PROM motions had an empty end-feel on B UE.

Strength

Manual muscle testing was used to assess the muscular performance as described per Berryman

Reese23. The patient had severe decreases in bilateral upper extremity flexion, abduction, external

rotation and internal rotation. He was unable to perform full ROM with gravity eliminated. Therefore, he

performed 3-/5 in terms of the previously listed motions. Refer to table 3. The intrarater reliability of the

MMT grades of 0 to 5 ranged from 0.80 to 0.9923.

Joint Play Assessment

Joint play assessment was utilized to assess passive movement of the articular surface of the

glenohumeral joint (GH) as described by Magee24. The patient demonstrated hypomobility and

increased pain with a posterior and inferior glide of the left and right GH joints. Also, the patient had

increased numbness and tingling with an inferior glide of the left GH.

Sensation

Light touch sensation testing was performed on bilateral upper extremities as described per

Berryman Reese23. The patient had positive findings for L upper extremity C7 and C8 dermatomal

patterns. These positive findings were not new to the recent injury as subjectively reported by the

patient. There were no abnormal findings in the dermatomal regions of right upper extremity C5, C6, C7,

and C8 and left upper extremity C5 and C6.

Special Tests

Special testing was performed as per Magee24. The patient had tested positive bilaterally for

instability of glenohumeral joint (Apprehension Test) and impingement (Hawkins Kennedy, Painful Arc,

Neer Test). The right GH also tested positive for biceps (Speed’s sign) involvement and Yergeson’s.

Negative findings included bilateral Spurling’s to cervical and distraction of cervical spine. All other

special testing considered negative if not listed. The Hawkin’s-Kennedy test has a sensitivity of .79 and a

specificity of .59 for impingement26. Speed’s Test has a sensitivity of .90 and a specificity of .14 for

biceps long head pathology and SLAP lesions25. Yergason’s Test assesses the long head of the biceps,

checks the presence of the transverse humeral ligament and has a sensitivity of .8617. A painful arc is

approximately between 70-120 degrees with AROM and has a 80.5% specificity as per Calis17. Neer Test

has a sensitivity of .89 and a specificity of .3128. Apprehension Test had a specificity of 98.91% and a

sensitivity of 52.78%27. Spurling’s Test has a 94% specificity which allows for a good screening test for

cervical radiculopathy29.

Clinical Impression #2

The findings of the examination supported signs and symptoms consistent with bilateral partial

supraspinatus tears and right biceps tendon partial tear. The patient also had multiple risk factors that

predisposed him to be at increased risk for rotator cuff tear: past shoulder injury, age, scapulothoracic

dyskinesia, and a repetitive and physical demanding occupation. The negative Spurling’s Test ruled out

cervical involvement, but his prognosis is decreased secondary to a past history of a cervical fusion and

neurological sensation deficits. His goals are to decrease pain and improve functional mobility to return

to work and play with his grandchild.

Intervention

Week 1 – The main objective during week one was to utilize anti-inflammatory strategies to address

increased pain and decreased ROM at bilateral shoulder girdles using electrical stimulation, ice, and

manual therapy. This included soft tissue mobilization, PROM, grade IV mobilizations to bilateral

glenohumeral joints for posterior and inferior capsules, active release, and trigger point release. The

major muscles addressed were bilateral upper trapezius, levator scapulae, pectoralis major, pectoralis

minor, subscapularis, biceps long head tendon, biceps brachii, teres major, supraspinatus, infraspinatus,

and rhomboids. Stretching exercises including biceps wall stretch, external rotation at the side, internal

rotation up mid back with green band, and manual stretching. AAROM was progressed to pulleys, table

slides in sitting, wall slides in standing, and cane assisted exercises into flexion, scaption, and abduction.

Parameters included the following: stretching exercises held 4 sets of 15 sec repetitions, Grade IV

mobilizations were performed 3 sets of 90 second oscillations per joint mobilization, and therapeutic

exercises included 3 sets of 15 repetitions.

Week 2 – The same modes of treatment were used as week 1 secondary to the patient presenting to

therapy in the inflammatory process. Pt reported enormous decreases in subjective reports of pain post

therapy session. However, he was continually having set-backs post each workday.

Week 3 – The same mode of treatment utilized as week 1 and 2. However, the therapist progressed the

patient to Sahrman’s AAROM wall slides to tolerance and incorporated IR/ER at 0 degrees abduction

with towel under arm and a resistance of the yellow thera-band to initiate strengthening in the pain free

range.

Week 4 – Incorporated iontophoresis to R anterior shoulder – Utilized 1.0cc dexamethasone extra

strength patch onto right biceps longhead tendon to decrease inflammation. Continued to perform

similar manual, anti-inflammatory/pain relieving strategies, and ther-ex as weeks 1, 2, and 3.

Week 5 – Patient had cortisone injection in R GH. He reported a severe increase in pain and was unable

to move his R UE over the next three days. Then, he reported an extreme decrease in pain and an

increase in AROM in all R GH motions. The L UE was extremely painful and showed decreased ROM

measurements. All AROM and AAROM exercises were held on the L UE secondary to the pain increase.

Only manual and anti-inflammatory/pain relieving strategies were performed as stated previously.

Week 6 – Treatment consisted of continued manual therapy, anti-inflammatory/ pain-relief strategies,

and AAROM exercises as stated previously. The PT progressed therapeutic exercises on the R UE to

incorporate thoracic stability exercises.

Outcomes

Following a 6 week physical therapy treatment as describe above, the patient demonstrated

improvements in R GH subjective reports of pain, AROM, PROM, and functional abilities. However, the L

GH showed higher reports of pain, decreased AROM, decreased PROM, and decreased functional ability.

The patient had a statistically significant improvement of the total SPADI score on the R UE by 40 points

from the initial assessment to the final assessment. The patient’s L UE had a statistically significant

decline in total SPADI score from initial to midterm but did not have a statistically significant change

from initial to final assessment (refer to Table 4).

The patient’s AROM on the R UE had statistically significant improvements in GH flexion,

abduction, external rotation, and internal rotation. The patients AROM on the L UE had significantly

different decreases in regards to flexion, abduction, internal rotation, and external rotation (refer to the

table 1). The patients PROM improved on the R UE by 50 degrees in flexion, 57 degrees in ABD, and 22

degrees in external rotation. The L UE had a decline in IR PROM by 17 degrees (refer to table 2).

The patient’s strength improved on the R UE (3-/5 initial; 3+/5 final) in terms of his flexion,

abduction and external rotation. His internal rotation strength improved (3-/5 initial; 4-/5 final). There

were no significant changes in L UE muscular performance over the 6 weeks (refer to table 3).

The patient’s work restrictions did not change over the course of the 6 week intervention. He

was on a 20 pound limit for pushing/pulling/lifting and no lifting overhead. However, his work consisted

of constant reaching and working with arms away from the body. The patient had a severe difficulty

with the repetitive nature of the work tasks he was performing. He reported having extreme increases in

pain throughout the work day secondary to repetitive reaching tasks and use of hands away from the

body. Pt was unable to lift >20 pounds from floor to waist and was unable to lift overhead with any

resistance.

Discussion

The purpose of this study was to examine the impact that return to work with restrictions has

on overall outcomes of a repetitive, upper extremity reaching job in a patient with bilateral rotator cuff

pathology and a workers compensation claim. The patient was progressively getting worse by midterm

assessment in regards to AROM, PROM, and subjective reports of pain and disability (SPADI). This

regression was not consistent with the literature. There are multiple variables that may have played a

role in this decline. However, most of the variables are due to the repetitive reaching tasks done at

work. Constant reaching with an outstretched arm requires the ability to perform a static lift of at least

10 pounds with his arm elevated to 90 degrees 18. This would result in the patient to be able to perform

constant reaching (67-100% of the workday) with objects weighing <1 pound 18. Since the patient was

constantly working with objects between 5-10 pounds away from his body, he would have needed to

perform a static lift in the arm elevated to 90 degrees with 50-100 pounds according to Blankenship’s

calculation of ergonomic lifting ability 18. His strength was impaired on B UE to 3+/5 which gives means

he could not perform reaching tasks with any resistance. Therefore, this should have resulted in the

patient’s work restrictions limiting him to no work away from the body until he was able to perform the

required lifting task. This work could have led to recurrent impingement, repetitive tissue injury, and

increased risk for other contributing factors, such as scapular dyskinesia, that may have decreased his

healing ability.

Scapular dyskinesia is defined as the abnormal movement of the shoulder blade. Research

stated that weakness of the scapula-thoracic musculature may cause or aggravate impingement4. If

humeral elevation is not synchronized with upward scapular rotation or lowering of the arm is not

synchronized with downward scapular rotation, impingement may occur4. Scapular tipping (rotation

about a medial to lateral axis) and serratus anterior muscle function are important to consider in the

rehabilitation of patients with symptoms of shoulder impingement related to occupational exposure to

overhead work13. After each workday, the patient had severe increases in pain even though he was

adhering to his work restrictions. This being said, his work restrictions did not incorporate working with

an outstretched arm which would have put him at increased risk for impingement and stress of the

injured tissue. In workers compensation cases, the goal is to get the patient back to work as quickly as

possible. This may have negatively impacted the patient’s healing ability, time to full recovery, and

ultimately led to increased cost of treatment. The type of occupation the patient performs is a key

variable in determining the work restrictions and frequency of repetitive tasks.

There were a few other variables that should have been taken into consideration when

determining the patient’s potential. First, the patient underwent a cortisone injection in the R UE which

was used to decrease inflammation in the injected area, and he had significant increases in ROM,

decreased pain, and improved subjective disability ratings post-cortisone injection. This gave the

impression that the patient was performing work duties that led to increased inflammation and tissue

damage since he had improved outcomes once the inflammation was controlled. There was strong

evidence that corticosteroid injections were beneficial in short term treatment of rotator cuff tears but

can actually lead to worse long-term outcomes21,22. Second, the patient had a history of cortisone

injections which may have played a role in the deterioration of the injured tissue. Third, the patient’s

age may have increased his risk for decreased prognosis. Injured workers who returned to work were

more likely to be better educated and under 50 years of age19. Also, the bilateral nature of his injury may

have also lead to decreased prognosis though there is limited research on this area. However, if the

patient had an extremity that was not injured, they would be able to give the involved extremity rest

and utilize the un-involved side more for the aggravating tasks leading to decreased risk of re-injury.

Finally, his past history of cervical fusion is important to consider. Cervical radiculopathy or nerve palsy

can contribute to scapular dyskinesia and/or instability which may have increased the risk for

impingement and is found in as many as 68% of rotator cuff problems7.

As stated previously, past research indicates that deficits will occur in the acute stages of a

shoulder injury, and the patient should be educated to avoid/minimize activities in which the arm is

raised above shoulder height to avoid motions that create impingement20. However, in this patient case

the doctor’s work restrictions did not specifically attend to this. This may have led to increased

impingement, re-injury of the tissues, and decreased healing ability. Once the inflammation was

addressed via corticosteroid injections on the R UE, the patient had significant improvements in ROM

and functional ability.

The limitations of the case study include the short duration of the treatment, the use of multiple

interventions, and a lack of long-term follow-up. The current research stated the minimum amount of

time recommended for conservative treatment of rotator cuff pathology is 6 months and the patient has

a 66% likelihood of having good to excellent results in that time frame2. The patient was at decreased

prognosis based on age, repetitive nature occupation, and had a prior history of shoulder pain and

corticosteroid injections but none were associated with decreased prognosis2. There was not much

research on bilateral shoulder injuries and workers compensation cases in regards to returning to work.

Future research should be conducted to determine proper treatment including the return to work on

specific work restrictions and the nature of his job duties with the bilateral nature of his injury.

Conclusion

There are many variables that negatively affect the healing process of a musculoskeletal injury

such as a rotator cuff tear including overhead reaching tasks, scapular dyskinesia, age, shoulder girdle

strength, workers compensation, and past medically history. During early stages of healing it is

important to allow for the tissue to repair itself and go through the inflammatory process. If the patient

continues to stay in the inflammatory stage of healing secondary to reinjuring the tissue every work day,

then the recovery is going to be longer and less likely to occur. Overall, an in-depth analysis of the job

duties needs to be completed before the patient’s work restrictions are made and determining the

appropriate time to return-to-work is crucial in optimizing the prognosis of the patient.

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TABLES

Table 1. Shoulder active range of motion measurements in degrees as described by Norkin and White10.

Table 2. Shoulder passive range of motion measurements in degrees as described by Norkin and

White10.

Table 3. Shoulder muscular performance assessment using MMT grades as described by Berryman

Reese23.

Active Motion Initial Mid Final

Left Right Left Right Left Right

Flexion 0-128 0-114 0-88 0-85 0-95 0-160

Extension 0-48 0-47 WNL WNL NA WNL

Abduction 0-129 0-110 0-97 0-107 0-110 0-160

Adduction WNL WNL WNL WNL WNL WNL

External Rotation 0-70 0-60 0-39 0-36 0-60 0-82

Internal Rotation 0-49 0-52 0-38 0-49 0-50 0-70

Passive Motion Initial Mid Final

Left Right Left Right Left Right

Flexion 0-130 0-115 0-102 0-98 0-134 0-165

Extension 0-50 0-50 WNL WNL NA WNL

Abduction 0-133 0-111 0-101 0-112 0-139 0-168

Adduction WNL WNL WNL WNL WNL WNL

External Rotation 0-71 0-64 0-47 0-45 0-66 0-88

Internal Rotation 0-69 0-85 0-42 0-54 0-52 0-72

Motion Initial Grade Mid-Grade Final Grade

Left Right Left Right Left Right

Flexion 3-/5 3-/5 3-/5 3-/5 3-/5 3+/5

Extension 5/5 5/5 5/5 5/5 5/5 5/5

Abduction 3-/5 3-/5 3-/5 3-/5 3-/5 3+/5

Adduction 5/5 5/5 5/5 5/5 5/5 5/5

External Rotation 3-/5 3-/5 3-/5 3-/5 3-/5 3+/5

Internal Rotation 3-/5 3-/5 3-/5 3-/5 3-/5 4-/5

Table 4. Outcome Measure Assessment - SPADI

Outcome Measure Right Left

SPADI Initial – 0 weeks Pain Scale = 37/50 Disability Scale = 42/80 Total = 79/130

Pain Scale = 32/50 Disability Scale = 41/80 Total = 73/130

SPADI Midterm – 3 weeks Pain Scale = 42/50 Disability Scale = 47/80 Total = 89/130

Pain Scale = 35/50 Disability Scale = 46/80 Total = 81/130

SPADI Final – 6 weeks Pain Scale = 23/50 Disability Scale = 26/80 Total = 49/130

Pain Scale = 31/50 Disability Scale = 44/80 Total = 75/130