Professional Papers
_______________________________________________________
Conservative management of
selected shoulder problems
Franklin Schoenoltz, DC, DABCO
Arcadia, California
Shoulder problems associated with pain present a challenge in diagnosis and
treatment to all clinical practitioners because of the complexity of the etiologies.
In this paper, an attempt will be made to discuss the differential diagnosis of the
most common entities affecting the shoulder joint and its conservative therapeutic
management.
Introduction
The terms bursitis, tendinitis, pericapsulitis, ad-
hesive capsulitis, frozen shoulder, etc have been used by
clinicians for years to describe generalized shoulder pain.
In many disorders of the shoulder, the lesion has not been
defined accurately. This paper will furnish the doctor of
chiropractic with information on the most common shoul-
der problems seen in everyday practice. Consideration
of other conditions should not be overlooked and will be
discussed briefly, but extensive material would have to be
presented which is beyond the scope of this paper.
Pathophysiology
Tendinitis is a reaction to mechanical wear and
tear plus degeneration. In the shoulder, degeneration
begins in the soft tissue. The rotator cuff bears the brunt
of the mechanical stress, leading to premature aging.
It should be noted that the tendon normally is a
wide ribbon made up of bundles of collagen fibers. The
fibers widen slightly as they are anchored into the hu-
meral tuberosity. Fibroblasts and a few blood vessels lie
between the bundles. Degeneration begins in the collagen
fibers and in the ground substance between the fibers.
As the tendon becomes roughened, its tensile strength is
decreased leading to fibrinoid degeneration and followed
by fibrosis.
The subacromial bursa is most likely to be affect-
ACA Journal of Chiropractic/October 1979
Copyright The Journal of the American Chiropractic Association
Copyright Dr Franklin Schoenholtz 2009
Dr Franklin Schoenholtz is a diplomate of the American Board of
Chiropractic Orthopedists. He maintains a private practice at 226-228
East Foothill Blvd. In Arcadia, California. He has taught diversified
technique and undergraduate orthopedics at the Los Angeles College
of Chiropractic in Glendale, California, from 1964-1976. Presently,
Dr Schoenholtz is the secretary-treasurer of the Board of Regents
at LACC. He has authored numerous articles on the manipulative
management of various musculosketela conditions. The most recent,
“Conservative Management of Cervical Tension Cephalagia,” ap-
peared in the June 1979 issue of the ACA Journal.
ed, losing its filamentous proportions and developing thick
walls with redundant folds. Microscopic examination reveals
that the normally smooth synovial surface changes, replaced
by fibrous tissue.
Calcific tendinitis of the rotator cuff may occur at
a later date. Microtraumatic injuries sustained by the cuff
cause necrotic and degenerative changes in the tendon tis-
sue. With necrotic and degenerative changes in the tendon
tissue. With necrosis, the localized tissue becomes alkaline
which induces precipitation of calcium to the area The de-
posits vary in consistency from a watery paste to powdery
granules.
The critical zone most often disturbed by these
deposits is the supraspinatus insertion. The calcium often
ruptures into the bursa but rarely goes toward the opposite
direction of the joint.
Diagnosis
In degenerative tendinitis, the patient is usually
middle-aged and complaining of localized pain in the anterior
lateral aspect of the shoulder. The initial symptom is pain
which is proportionate to the swelling of the tendon and
the pain threshold of the patient. Discomfort is encountered
Figure 1. Anatomy of the shoulder girdle with illustrations of the normal range of motion of the shoulder.

Figure 2. The “sit” muscles of the muscular cuff. Figure 3. Shoulder extension will move the rotator
cuff into a palpable position.
upon abduction starting at 70°, reaching its maximum inten-
sity before 90°, and disappearing as the humeral head passes
under the overhanging arch.
Characteristic of this condition is a nocturnal ach-
ing pain. As the symptoms develop, and abnormal shoulder
girdle rhythm occurs replacing fluid, effortless scapulohumeral
motion. Abduction becomes limited at the glenohumeral joint
and is substituted by a “hunching” (elevation) movement.
The scapula and humerus move together as one unit and the
range of motion may become severely limited.
The continuous severe pain results from the confine-
ment of the insulted swollen tendon within the narrow con-
tainer, causing a constant tension. Protective muscle spasm
intensifies the restricted mobility.
Degenerative tendinitis should be differentiated from
cervical root lesions or radiating patterns of neurovascular
compression syndromes.
Examination
The shoulder is one of the most interesting joints
of the body to examine. The shoulder moves within certain
physiological limits and the interpretation of findings is gener-
ally a matter of functional anatomy. (Figure 1)
Special maneuvers for differential diagnosis of primary
shoulder dysfunction may present symptoms which are ac-
curately related to shoulder and arm motions.
In order to establish a precise diagnosis, the examiner
Figure 4. The examiner tests abduction by placing the
upper hand over the deltoid to stabilize the shoulder. The
lower hand presses on the lateral aspect of the elbow as
the patient attempts to abduct his arm.
must reach the tissue at fault. The specific maneuvers are
herein presented along with their condition.
● Rotator cuff – The cuff is composed of four muscles.
Three of these muscles may be palpated as a unit where
they insert into the greater tuberosity of the humerus. These
muscles have become known as the “sit” muscles because
their initials spell the word sit. (Figure 2)
The sit muscles include the supraspinatus, the in-
fraspinatus and the teres minor. The subscapularis is the
fourth muscle of the cuff and is not palpable because of its
anterior position.
When palpating the muscular cuff, the doctor should
attempt to reproduce the pain caused by the defect. The tech-
nique for this procedure is to passively extend the shoulder so
that the cuff rotates forward from underneath the acromion.
The examiner should hold and lift the patient’s arm posteriorly
(Figure 3). Palpation will reveal the roundness of the rotator
cuff slightly anterior and inferior to the anterior border of the
acromion. Deep digital pressure may elicit diffuse pain, sug-
gesting a lesion of the cuff.
● Supraspinatus tendinitis – Supraspinatus tendinitis is
the most common problem affecting the shoulder joint. This
condition may be tested with the examiner placing one hand
over the deltoid muscle to stabilize the shoulder girdle. The
examiner then presses on the lateral aspect of the elbow while
the patient abducts his arm against resistance. The pres-
ence of pain on this maneuver incriminates the supraspinatus
muscle. (Figure 4)
To rule out deltoid involvement, the examiner holds
the patient’s arm passively at the horizontal plane. The patient
is asked to move his arm forward and backward against resis-
tance. If the pain is felt by the patient, involvement of the an-
terior and posterior fibers of the deltoid is indicated. However,
if neither of these movements causes pain, the supraspinatus
muscle is suspected.
● Rotator cuff tears – When a tear in the rotator cuff is
suspected, the “drop arm test” may be performed. The patient
is asked to fully abduct his arm. When a tear is present in
the cuff, the patient will be unable to slowly lower his arm. It
will drop to his side from a position of 90° abduction. If the
patient is able to hold his arm in abduction, a mild tap on the
forearm will cause the arm to fall. (Figure 5)
● Bursitis – There is an informative diagnostic procedure
which has been referred to as the “coracoid push button sign.”
The examiner presses firmly into the deltopectoral triangle.
The coracoid process may be felt at its tip and medial surface,
and lies under the pectoralis major muscle. Deep palpation
will normally elicit tenderness (Figure 6). The examiner should
slide his finger tip one-half inch laterally and superiorly until
he reaches a portion of the subacormial bursa. The clinician
should then press firmly with the same pressure as exerted
on the coracoid process. If a subacromial bursitis is present,
greater pain will occur, thus providing a differential sensation
scale, and suggesting that the condition involves the bursa.
A painful arc may be observed when the patient
attempts to raise his arm and momentarily falters before
reaching the horizontal. The patient compensates by bring-
ing his arm forward into the sagital plane before the hori-
zontal is reached. The arc is so severely affected that active
elevation stops and the patient may use his other arm to
push his affected arm further up. Calcification in the subac-
romial bursa or calcification of the rotator cuff is suggested.
● Bicipital tendinitis – Mechanical tensoynovitis involves
the tendon and its sheath gliding mechanism. The gliding
mechanism becomes disturbed by excessive activity of the
arm or by direct trauma to the area of the bicipital groove.
All activities which require much motion of the humerus on
the bicipital tendon will produce pain, eg, putting on a shirt
or combing of the hair will irritate the biceps tendon and
cause pain. If bicipital tendinitis is present, the patient will
keep his arm flexed at this side for maximum comfort.
Deep palpation at the medial border of the deltoid
produces tenderness along the bicipital tendon as the arm is
rotated externally.
A specialized test for bicipital tendinitis may be per-
formed by having the patient flex his arm and supinate his
hand against resistance. In bicipital tendinitis, this maneu-
ver will produce pain which is referred to the front and inner
Figure 4. The examiner tests abduction by placing the
upper hand over the deltoid to stabilize the shoulder.
The lower hand presses on the lateral aspect of the
elbow as the patient attempts to abduct his arm.
aspect of the shoulder. (Figure 7)
Radiological Examination
The value of radiographs in tendinitis is to eliminate
an overriding pathological lesion which is impossible to de-
tect clinically.
When calcium deposits are seen on x-ray, the physi-
cal characteristics will greatly influence the type of pain felt
by the patient. When the calcium appears undefined at the
marginal borders with a cloudy appearance, it may be in a
soft state. This phase is most identified with an acute pro-
cess characterized by severe, throbbing shoulder pain with
marked disability. In the chronic phase, the calcium deposit
appears gritty with greater radiopacity. The clinical picture
is characterized by a chronic shoulder pain and a “catching”
pain brought about by raising the arm in abduction.
Anteroposterior x-ray views of the shoulder taken
with the arm in both external and internal rotation may re-
veal calcium deposits in the rotator cuff.
The examiner’s judgment becomes paramount in
establishing a clinical relationship between the calcium and
its effect on the symptom complex.
Treatment
Figure 6. Palpation of the coracoid process.

Degenerative tendinitis is a chronic condition which usu-
ally can be treated successfully by conservative measures. The
principles of treatment include relieving the pain, restoring the
shoulder movements and avoiding the irritating activities.
● Cryotherapy – Cryotherapy, rather than thermotherapy, is
indicated during the acute period which usually ranges from 48
to 72 hours.
Direct ice massage provides surface anesthesia. The
patient usually responds to the therapy in four stages: cold,
burning, aching and numbness. When the skin becomes cold, it
turns red and a histamine-like reaction occurs during the remain-
ing three phases. The patient may become conscious of a tender
mass over the site of maximum pain, usually at the insertion of
the supraspinatus tendon. When this sensation passes, usually
after two to four minutes, the pain is relieved and surface anes-
thesia begins.
Because of lower thermal conductivity of subcutaneous
fat tissue, application of ice for short time periods will not affect
deeper tissue; the only effect is to lower the skin temperature.
Observations have been made that the intramuscular tempera-
ture, at a depth of three centimeters, is not affected until a cool-
ing period of 10 minutes has elapsed. Optimum ice therapy is
recommended for a period of 20 to 30 minutes every three hours
during waking periods.
The technique recommended by the author involves
the freezing of water in a paper cup along with a wooden stick
(which later can act as a handle). When the ice cylinder is to be
used, the paper cup is pulled off and the patient is able to apply
direct ice massage over the site of the lesion.
Direct ice massage and cold packs on the skin act as
decongestants and decrease localized edema and inflammation.
Clinically, this treatment decreases muscle fatigue and helps re-
duce muscle spasticity to facilitate gentle limbering movements.
● Thermotherapy – Thermotherapy should be utilized as a
preliminary procedure to the mobilization of a joint. Heat should
be introduced in the post-acute stage since it will enhance blood
circulation, contribute to muscular relaxation and improve the
nutritional supply to the tissue involved.
● Ultrasound and high voltage galvanism – Ultrasound
combined with pulsating, high-voltage galvanic current in the
clinical management of degenerative tendinitis offer excellent
results.
Ultrasound creates a “micro-massage” of the cellular
tissues, producing mechanical vibrations which increase blood
supply, stimulating metabolic activity and yielding an analgesic
effect. In interstitial myofibrositis, ultrasound mechanically ir-
ritates the mast cells to enhance degranulation. Further consid-
erations lie in its ability to soften scar formations and to dissipate
soft calcium deposits.
Current developments have shown that ultrasound, in
combination with high-voltage, pulsed galvanic current up to
500 volts, promotes relief of pain and lessens tissue swelling.
The pulsed current causes a greater mechanical pumping of the
muscle. When excessive catabolites are present in the muscle,
the pulsed current attempts to remove the catabolites by stimu-
lating capillary circulation. Muscle stimulation permits the activa-
tion of the muscle without using it to move the joint (similar to
an isometric exercise).
This author’s technique involves strapping the large
dispersive pad (8” x 10”) to the patient’s thoracic region and ap-
plying ultrasound over the site of the lesion. The intensity varies
from one to 1.5 watts per square centimeter. Positive galvanic
current is increased to the patient’s tolerance, which is an aver-
age of 400 volts. Each therapy session lasts approximately 10
minutes. (Figure 8)
● Mobilization therapy – Mobilization therapy is the treat-
ment of choice since continued immobilization will contribute to
ischemia, metabolic retention, edema, adhesive capsulitis and
disuse atrophy.
Restoration of pain-free movement is the most important
aspect of treatment. As soon as the initial reaction has subsided,
a treatment program may begin to restore and preserve normal
range of motion.
Gentle passive motion of the glenohumeral joint may be
performed by an office therapist.
Passive assistive mobilization of the shoulder may be
achieved by having the therapist place one hand in the axillary
region beneath the affected shoulder and grasp the upper end
of the forearm with the other hand. Counteraction is applied to
the axillary border of the scapula. The therapist gently attempts
to separate the humeral head away from the glenoid fossa by
abducting and externally rotating the arm. (Figure 9)
This procedure may be repeated to the patient’s toler-
ance level. A rugged technique must always be avoided since
it may exacerbate the symptoms. This technique attempts to
stretch the capsule and reduce adhesions.
● Home exercise program – Following subsidence of the
acute phase, active mobility is encouraged. Exercises must not
be severe or the patient will regress and severe immobility may
occur.
A valuable exercise which minimizes impingement and
avoids abduction is a pendular exercise. This author recom-
mends the “soup can” exercise, which adds mild traction to the
dependent arm and stretches the capsule.
The patient is instructed to sit comfortably with his arm
relaxed at his side, holding a ten ounce “soup can.” The patient
swings his arm slowly in a rotatory clockwise direction for 15
minutes and then reverses the direction for an additional 15
minutes. This procedure should be performed twice daily. It is
noteworthy that the “soup can” must be held loosely so that
proximal muscular contraction of the shoulder muscle does not
occur. Tension in the shoulder muscles will defeat the usefulness
of the weight. (Figure 10)
Figure 7. In bicipital tendinitis, pain will be referred to
the front and inner aspect of the shoulder when the
patient supinates his hand against resistance.
Figure 9. I passive assistive mobilization of the shoul-
der, the arm should be rotated gently by the therapist.
Countertraction should be exerted for separation of the
humeral head away from the glenoid fossa.
Figure 8. The technique for combined ultrasound and
high voltage galvanic current.
Figure 10. The “soup can” exercise should be per-
formed by having the patient swing his arm passively in
a rotatory movement. The can must be held loosely so
that the proximal muscular contraction of the shoulder
muscles does not occur.
Figure 11. The finger walking exercise should be performed in a slow, deliberate manner with concentration.
The patient should be instructed to use as much normal scapulohumeral rhythm as possible.

Figure 12. Deep transverse massage is performed in the bicep tendon with a finger position similar to pinching.
 As the symptoms subside, active, unresisted abduc-
tion exercise should be introduced such as the “finger walking
wall” exercise. This exercise must be performed in a slow,
deliberate manner with concentration. The patient should be
instructed to use as much normal scapulohumeral rhythm as
possible. Hunching of the scapula to achieve abduction should
be avoided.
The patient should stand laterally at arms’ length
from the wall and “walk” his fingers upward and downward
for a five-minute period. The patient should then face the wall
and extend his arm in front, repeating the same procedure for
the same length of time. Three sessions per day are recom-
mended for this exercise. (Figure 11)
Pain tolerance varies with the patient and professional
judgment must be a determining factor in any suggested
exercise program.
● Friction therapy – Tendinitis of the long head of the
bicipital tendon responds favorably to deep transverse friction.
Manual rolling of the tendon sheath serves to reduce inflam-
mation. The usefulness of deep friction may be difficult to
understand unless the assumption is made that scar tissue is
capable of being broken down by manual mobilization. Never-
theless, this type of therapy may achieve superb results.
Although the causative trauma may have involved
longitudinal stress, the therapeutic technique is directed
towards transverse mobilization of the sheath on the bicipital
tendon.
The patient’s arm should be flexed and the shoulder
should be externally rotated to ease palpation of the bicipital
groove. The long head of the bicipital tendon is felt proximally
by the thumb and first finger. Deep friction massage is per-
formed with a finger position similar to “pinching,” for a total
of ten minutes. Two to six treatments may be required until
symptoms abate. (Figure 12)
● Summary
The complexity of the tendinitis syndrome should be
treated by utilizing all necessary modalities to restore range of
motion. Prolonged immobilization must be avoided since it may
cause frozen shoulder.
Effective treatment of the shoulder requires effort, pa-
tience and understanding on he part of the doctor.
The treatment program may be long and progress may
be slow. The patient must be encouraged to cooperate so that
anxiety and depression do not interfere with the long-range goal
of a complete pain-free restoration of shoulder movement.
As the treatment program proceeds, the doctor and
the patient will benefit from an occasional progress review. The
patient’s active participation in the therapeutic program will help
achieve the objective of optimum health and functioning of the
shoulder.□

The author wishes to thank Tuan Tran, PhD. for his editorial as-
sistance in the preparation of this clinical paper.

Bibliography

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2.Cailliet: Shoulder Pain, 1975.
3.Cailliet: Soft Tissue Pain and Disability, 1977.
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5.Cyriax: Textbook of Orthopedic Medicine, 1976.
6.Cyriax: Treatment of Manipulation and Deep Massage, 1959.
7.Gartland: Fundamentals of Orthopedics, 1974
8.Goodley, Paul, MD: Personal communication, 1979
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11.McMasters: “When to Use Ice for Injuries,” Consultant,
1977.
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Copyright The Journal of the American Chiropractic Association

Copyright Dr Franklin Schoenholtz 2009