CHRIS FJOSNE, PT, DPT, OCS

Rehabilitating Impairments of the Painful Shoulder

Objectives

Understanding the stages and treatment of 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 RadiculitisFrozen ShoulderTendinopathy

Tendinosis/Tendinitis Full thickness RC tears Partial thickness tears Impingement Bursitis

Cervical Screen

Upper Limb Tension TestSpurlingsDistractionCervical rotation <60° to involved side

3 of 4 (+) tests demonstrates 94% specificity 4 of 4 (+) tests demonstrates 99% specificity

Frozen Shoulder

Adhesive CapsulitisRecognition-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 yearsInsidious or minimal trauma event resulting

in onsetSignificant night painSignificant limitations of active and passive

shoulder motion in more than 1 plane50% or greater than 30 degrees loss of

passive external rotationAll end ranges painfulSignificant pain and/or weakness of the

internal rotators

Etiology and Pathology

Although precise etiology remains unclear, evidence 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 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 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 9-15 months duration Minimal pain except at end

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

Stage 4 15-24 months duration 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 medicationsCorticosteriod injectionsExerciseJoint mobilizationDistensionAcupunctureManipulationNerve blocks

Phase 1 Treatment

Moist hot packs/electrical stimulation for painFrequent pain-free AAROM exercisesPendulum exercisesSingle plane mobilization (I, II)Soft tissue mobilizationStretchingHome program (10-12 times daily light

motion)Intra-articular corticosteriod injections

Phase 1 AAROM

Phase 2 Treatment

Active warm-upAAROM exercisesSingle plane near end range mobilizations

(III)StretchingEnd range submaximal isometricsSelf-capsular stretchingPostural programHome program (frequent sustained end

range stretches 5-7 minutes in duration)

Phase 3 Treatment

Active warm-upLow load long duration stretch (LLLDS) with

heatAggressive joint mobilizations (IV) single and

multi-planar and combined glidesStretchingStrengtheningHome 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 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 weekly

Prefer daily ROM stretchingSelf-capsular stretchesRotator 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 StretchCross Body Capsular Stretch

Summary of Adhesive Capsulitis

Stiff shoulder vs. adhesive capsulitisAssess and determine the stage of pathologyAssess classification to determine

appropriate treatment phaseUnderstanding 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 Impingement

(Subacromial and Internal)

Anatomical and Biomechanical Variants

Intrinsic Mechanisms relates to within the tendon 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

Acromial shapeAcromial shape

Subacromial spursAC joint spurs Acromial shape and

slope

Anatomical Factors

Biomechanical Factors

Abnormal scapular 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 ageResearch 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 stretchingPosterior 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!