Rehabilitating Impairments of

the Painful Shoulder

CHRIS FJOSNE, PT, DPT, OCS

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 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

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

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

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

Stage 2

0-3 months duration

3-9 months duration

Chronic pain with active and

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

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

Minimal pain

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

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 patients end ROM reproduce the
patients 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

orientation of the connective tissues 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 stretching
Self-capsular stretches
Rotator cuff and scapular stabilization program to
begin once functional ROM restored
Activity modification

RCI Self Stretch

The patients 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

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

Anatomical Factors
Acromial shape

Subacromial spurs
AC joint spurs
Acromial shape and

slope

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 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?

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