1. Rehabilitating Impairments of the Painful Shoulder
Chris Fjosne, PT, DPT, OCS

2. 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

3. Differential Diagnosis
Cervical Radiculitis
Frozen Shoulder
Tendinopathy
Tendinosis/Tendinitis
Full thickness RC tears
Partial thickness tears
Impingement
Bursitis

4. Cervical Screen Upper Limb Tension Test Spurlings Distraction
Cervical rotation <60° to involved side
3 of 4 (+) tests demonstrates 94% specificity
4 of 4 (+) tests demonstrates 99% specificity

5. Frozen Shoulder

6. 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).

7. Primary vs. Secondary

8. Characteristics of Primary Frozen Shoulder
Patient age, years
Insidious or minimal trauma event resulting in 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

9. 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.

10. 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

11. 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.

13. Stages of Adhesive Capsulitis
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

14. Stages of Adhesive Capsulitis
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

15. Adhesive Capsulitis Diagnosis
Rule in if:
Pt. age is between 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

16. 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 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

17. Nonoperative Interventions
Oral medications
Corticosteriod injections
Exercise
Joint mobilization
Distension
Acupuncture
Manipulation
Nerve blocks

18. 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

19. Phase 1 AAROM

20. 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)

21. 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)

22. LLLDS is effective for improving Total End Range Time (TERT)
Lentell reported
Time: minutes
Frequency: 3-4x/day
Duration: 60min/day
Load added to stretch is (.5% BW)

23. 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.

24. 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

25. Home Maintenance Program
Continue stretching program at least 3-4 times weekly
Prefer daily ROM stretching
Self-capsular stretches
Rotator cuff and scapular stabilization program to begin once functional ROM restored
Activity modification

26. RCI Self Stretch
The patient’s hand remains fixed and the elbow is adducted toward the table.

27. Posterior Capsule stretch
Sleeper Stretch
Cross Body Capsular Stretch

28. 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.

29. RC Tendinopathy
Seitz 2010

30. 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

31. Subacromial space
The acromiohumeral distance(AHD) is the linear measure to between the acromion and humeral head used to quantify the subacromial space

32. Anatomical Factors Subacromial spurs AC joint spurs
Acromial shape
Subacromial spurs
AC joint spurs
Acromial shape and slope

33. Biomechanical Factors
Abnormal scapular kinematics
Abnormal humeral kinematics
Postural abnormalities
RC and/or scapular muscle performance
Soft tissue tightness

34. Scapular motions
Patients with normal scapular mechanics show upward rotation, slight external rotation and posterior tilting of the scapula during shoulder elevation.

35. 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

36. 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.

37. 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

38. 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.

39. 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

40. Ellenbecker & Cools 2012

41. 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

42. 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.

43. What if I need surgery?
Thank you and enjoy your next lecture!