Rehabilitating Impairments of
the Painful Shoulder
CHRIS FJOSNE, PT, DPT, OCS
Objectives
 Understanding the stages and treatment of
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Adhesive Capsulitis
Understanding of the mechanism underlying
rotator cuff disease
Outlining the stages of primary and secondary
impingement
Facilitating the development of evidence-based
strategies to treat rotator cuff impingement
Making the appropriate referral for treatment
Differential Diagnosis
 Cervical Radiculitis
 Frozen Shoulder
 Tendinopathy
 Tendinosis/Tendinitis
 Full thickness RC tears
 Partial thickness tears
 Impingement
 Bursitis
Cervical Screen
 Upper Limb Tension Test
 Spurlings
 Distraction
 Cervical rotation <60° to involved side
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3 of 4 (+) tests demonstrates 94% specificity
4 of 4 (+) tests demonstrates 99% specificity
Frozen Shoulder
Adhesive Capsulitis
Recognition-Classification
 Adhesive capsulitis- Nevaiser defined it as “the
inflamed and fibrotic condition of the
capsuloligamentous tissue.
Codman described frozen shoulder as “a condition
difficult to define, difficult to treat, and difficult to
explain from the point of view of pathology.”
 Stiff and painful shoulder: painful condition
with limited active and passive range of motion
(ROM).
Primary vs. Secondary
Characteristics of Primary Frozen Shoulder
 Patient age, 40-70 years
 Insidious or minimal trauma event resulting in
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onset
Significant night pain
Significant limitations of active and passive
shoulder motion in more than 1 plane
50% or greater than 30 degrees loss of passive
external rotation
All end ranges painful
Significant pain and/or weakness of the internal
rotators
Etiology and Pathology
 Although precise etiology remains unclear, evidence
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identifies elevated serum cytokine levels.
Cytokines and other growth factors facilitate tissue repair
and remodeling as part of the inflammatory process.
The inflammatory healing response can lead to excess
accumulation and production of fibroblasts releasing type
1 and type III collagen.
This exaggerated inflammatory response leads to
arthrofibrosis
Studies report focal vascularity and synovial angiogenesis
(increased papillary growth) rather then a synovitis.
Etiology and Pathology cont.
 However, it is agreed that whether it is
angiogenesis or synovitis that pain accompanies
the change.
 Open and arthroscopic examination demonstrated
significant capsuloligamentous complex (CLC)
fibrosis and contracture
 Also contracture of the rotator cuff interval (RCI)
is prevalent
Rotator Interval (RCI)
 The RCI forms the
triangular-shaped tissue
between the anterior
supraspinatus edge and
upper subscapular border,
and includes the superior
glenohumeral ligament
and the coracohumeral
ligament.
Stages of Adhesive Capsulitis
Stage 1
 0-3 months duration
 Pain with active and passive
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ROM
Limitation of forward flexion,
abduction, IR, ER
Exam under anesthesia:
normal or minimal loss of ROM
Arthroscopy: GH synovitis
(pronounced in anterosuperior
capsule)
Hypervascular synovitis
Stage 2
 3-9 months duration
 Chronic pain with active and
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passive ROM
Limitation of forward flexion,
abduction, IR, ER
Exam under anesthesia: ROM
is identical to when patient is
awake
Arthroscopy: diffuse
pedunculated synovitis
Hypervascular synovitis,
subsynovial scar, fibroplasias
Stages of Adhesive Capsulitis
Stage 3
Stage 4
 9-15 months duration
 15-24 months duration
 Minimal pain except at end
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ROM
Significant limitation of ROM
with rigid end feel
Exam under anesthesia: ROM
identical to when patient awake
Arthroscopy: No
hypervascularity, fibrotic
synovium, diminished capsular
volume
Capsule shows dense scar
formation
 Minimal pain
 Progressive improvement in
ROM
 Minimal data available for
exam under anesthesia
Adhesive Capsulitis Diagnosis
 Rule in if:
 Pt. age is between 40-65 years
 Pt. reports a gradual onset with progressive worsening of pain
and stiffness
 Pain and stiffness limit sleeping, grooming, dressing, and
reaching
 Glenohumeral passive ROM is limited in multiple directions
 Glenohumeral ER or IR ROM decreases as arm is abducted
from 45 to 90 degrees
 Passive motions into the patient’s end ROM reproduce the
patient’s reported shoulder pain
 Joint glides/accessory motions are restricted in all directions
Adhesive Capsulitis Diagnosis?
 Rule out if:
 Passive ROM is normal
 Radiographic evidence of glenohumeral arthritis is
present
 Passive ROM for ER and IR increases as you move
from 45-90 degrees and the reported pain is
reproduced with palpatory provacation of the
subscapularis myofascia
 Upper-limb nerve tension testing reproduces the
reported shoulder pain
 Shoulder pain is reproduced with palpatory
provocation of the relevant peripheral nerve
entrapment site
Nonoperative Interventions
 Oral medications
 Corticosteriod injections
 Exercise
 Joint mobilization
 Distension
 Acupuncture
 Manipulation
 Nerve blocks
Phase 1 Treatment
 Moist hot packs/electrical stimulation for pain
 Frequent pain-free AAROM exercises
 Pendulum exercises
 Single plane mobilization (I, II)
 Soft tissue mobilization
 Stretching
 Home program (10-12 times daily light motion)
 Intra-articular corticosteriod injections
Phase 1 AAROM
Phase 2 Treatment
 Active warm-up
 AAROM exercises
 Single plane near end range mobilizations (III)
 Stretching
 End range submaximal isometrics
 Self-capsular stretching
 Postural program
 Home program (frequent sustained end range
stretches 5-7 minutes in duration)
Phase 3 Treatment
 Active warm-up
 Low load long duration stretch (LLLDS) with heat
 Aggressive joint mobilizations (IV) single and multi-
planar and combined glides
 Stretching
 Strengthening
 Home program (4-6 times daily)
LLLDS is effective for improving Total End
Range Time (TERT)
 Lentell reported
 Time: 15-20 minutes
 Frequency: 3-4x/day
 Duration: 60min/day
 Load added to stretch is (.5% BW)
What do we need to know about connective
tissue?
 In the absence of normal joint movement, the normal
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orientation of the connective tissue’s collagen fibers is lost.
Long-lasting or plastic elongation is produced by exposing
connective tissue.
The effectiveness of a low-load long duration stretch (LLLDS)
to promote long-lasting elongation of connective tissue is well
documented.
Studies also support that the temperature of the connective
tissue at the time of the stretch can significantly influence the
long-lasting change that is produced.
Elevating the temperature of the tissue prior to the stretch
and during the stretch produced greater changes and less
tissue damage.
Joint mobilizations during Phase 3
 High-grade joint mobilizations are used to
promote elongation of shortened fibrotic soft tissue
 Mobilizations should be performed at or near
physiologic end range
 Improved extensibility of the any portion of the
CLC results in improved motion in all planes
 Multi-planar mobilization techniques utilize
rotational stress with concomitant translation
which loads the collagen in multiple planes
Home Maintenance Program
 Continue stretching program at least 3-4 times
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weekly
Prefer daily ROM stretching
Self-capsular stretches
Rotator cuff and scapular stabilization program to
begin once functional ROM restored
Activity modification
RCI Self Stretch
The patient’s hand
remains fixed and the
elbow is adducted
toward the table.
Posterior Capsule stretch
Sleeper Stretch
Cross Body Capsular
Stretch
Summary of Adhesive Capsulitis
 Stiff shoulder vs. adhesive capsulitis
 Assess and determine the stage of pathology
 Assess classification to determine appropriate
treatment phase
 Understanding and combining LLLDS, soft tissue
mobilizations and multi-planar mobilizations
 PT appropriate at all stages but patient may need
image guided intra-articular injection during painful
phase 1 of treatment.
RC Tendinopathy
Seitz 2010
Extrinsic vs. Intrinsic Mechanisms
 Extrinsic Mechanisms
relates to external
tendon compression or
shear
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Impingement
(Subacromial and
Internal)
Anatomical and
Biomechanical Variants
 Intrinsic Mechanisms
relates to within the
tendon
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Tendon Vascularity
Tendon Biology
Tendon Morphology
Genetic Predisposition
Subacromial space
 The acromiohumeral
distance(AHD) is the
linear measure to
between the acromion
and humeral head used
to quantify the
subacromial space
Anatomical Factors
Acromial shape
 Subacromial spurs
 AC joint spurs
 Acromial shape and
slope
Biomechanical Factors
 Abnormal scapular
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kinematics
Abnormal humeral
kinematics
Postural abnormalities
RC and/or scapular
muscle performance
Soft tissue tightness
Scapular motions
Patients with normal scapular mechanics show upward rotation, slight
external rotation and posterior tilting of the scapula during shoulder
elevation.
Factors leading to impingement
 Mobility Deficits
 Capsular stiffness, Glenohumeral internal rotation deficiency
 Stability Deficits
 Scapular dyskinesis, Capsular laxity, Acquired anterior
instability
 Neuromuscular control/Strength Deficits
 Scapular stability weakness, RC weakness, poor recruitment
patterns
Primary Impingement
 Primary Impingement-
compression of the RC
tendons between the
humeral head and
overlying anterior third
of the acromion,
coracoacormial ligament,
coracoid or AC joint.
Secondary Impingement
 Attenuation of the static
stabilizers of the GH
joint, such as capsular
ligaments and labrum,
from the excessive
demands incurred in
throwing or overhead
activities can lead to
anterior instability
Internal Impingement
 Internal impingement
occurs when the shoulder
is in a 90/90 position
and the undersurface of
the supra and infra
tendons become
compressed or pinched
between the humeral
head and the
posterosuperior gleniod
rim.
Rotator Cuff Tears
 Incidence increases with age
 Research shows that tears are present in 50% or
more of the patient population greater than 60 years
of age
 Typically overuse injuries with compressive and
shear forces
Ellenbecker &
Cools 2012
Rehabilitating patients with impingement
syndrome
 Pec minor stretching
 Posterior capsule
stretching and
mobilization
 Postural strengthening
and education
 RC and scapular muscle
strengthening and
retraining
 Focus on modifiable
factors
Summary
 Adhesive capsulitis and RC tendinopathy are two of
the most common diagnoses related to ongoing
shoulder pain.
 Research and evidence based practice demonstrates
positive functional outcomes when treated
conservatively with PT.
What if I need surgery?
 Thank you and enjoy your next lecture!