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Rehabilitating Impairments of the Painful Shoulder

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

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Rehabilitating Impairments of the Painful Shoulder

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  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 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).

  7. Primary vs. Secondary

  8. 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

  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.

  12. 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

  13. 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

  14. 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

  15. 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 palpatoryprovacation 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

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

  17. 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

  18. Phase 1 AAROM

  19. 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)

  20. 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)

  21. 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)

  22. 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.

  23. 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

  24. 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

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

  26. Posterior Capsule stretch Sleeper Stretch Cross Body Capsular Stretch

  27. 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.

  28. RC Tendinopathy Seitz 2010

  29. 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

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

  31. Anatomical Factors Acromial shape • Subacromial spurs • AC joint spurs • Acromial shape and slope

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

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

  34. 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

  35. 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.

  36. 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

  37. 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.

  38. 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

  39. Ellenbecker & Cools 2012

  40. 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

  41. 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.

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

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