Chronic or acute inflammation of the shoulder can result in stiffness of the shoulder capsule, severe pain, and occasionally severely limited motion. While treatment of a stiff/frozen shoulder can be very painful, it is generally not terribly complicated and improves in a reliable fashion. Physical therapy can also serve prepare the patient for consultation with an orthopedic surgeon, by restoring optimal shoulder flexibility, strength and function. Because normalized passive motion is a prerequisite to successful RTC repair, even patients with a diagnosed RTC will benefit from skilled physical therapy intervention.
BACKGROUND
Chronic inflammation from osteoarthritis, rotator cuff tears or rotator cuff arthropathy, chronic impingement syndrome (subacromial bursitis) can cause stiffness of the shoulder capsule, extending around the glenohumeral joint, and includes the shoulder ligaments. In some cases, inflammatory problems are physiological – such as in the case of diabetes – and patients may very quickly develop a painfully limited shoulder. The conventional wisdom among some has been that frozen shoulders are self-limiting over the course of 1-2 years.
While more recent research has determined that “extensive” physical therapy (16+ visits) is not superior to “supervised neglect” (demonstration/instruction of a home flexibility program) over the long term, this research generally has not addressed the real world components of poor home program compliance and/or anxiety regarding the extreme amount of pain involved in the stiff or frozen shoulder.
Our experience demonstrates that 6-10 visits (depending on stage, irritability of symptoms, patient anxiety, fear, and exercise compliance) of therapy is optimal for recovery over the long term, consistent with current research, less expensive than other alternatives, sorts surgical problems from non-surgical problems, and restores optimal strength and function, should surgical intervention be required.
While physical therapy for chronic shoulder impingement and rotator cuff tear/arthropathy is widely accepted as the proper course of treatment, many treatment programs only address shoulder weakness and not stiffness or function, leading to unsuccessful therapy outcomes.
IMPLEMENTATION
Patients start therapy with range of motion exercises with overpressure – meaning that end of range is always reached, and mild to moderate additional pressure is applied at the end of the movement, to provide a stretch and increase available movement. We preferentially begin with scapular plane elevation, and external rotation at/near neutral and at/near 90 degrees of abduction.
PROGRESSION
In cases of severe pain, the patient may engage in passive range of motion (PROM) utilizing a table or desk, however, most of the time treatment starts with active-assisted range of motion (AAROM) in supine. Once an appropriate home program has been started, the treating therapist will utilize manual stretching techniques or joint mobilization to attempt to facilitate better progress. In some cases, patients tend to guard and make less progress being stretched manually than with AAROM or PROM and self-stretching, while other patients will realize better improvements with manual, hands-on treatments.
Once progress has been made in scapular plane elevation (scaption) and external rotation, then internal rotation is pursued. Range of motion exercises with overpressure are replaced with longer duration stretches, which are moved from supine to standing and eventually to prone (on the bed) with body weight applied. Later in therapy manual therapy is applied to the cervical and thoracic spine along with strength training of the rotator cuff, postural musculature, and shoulder girdle is initiated.
Frozen shoulders must be treated with care with respect to progression. “Freezing” shoulders are much different than “Frozen” or “Thawing” shoulders. Exercise dosage should never leave the patient more painful for longer than 30 minutes or so.
DISCHARGE
Depending on the needs of the patient, the treatment program continues through sports-related or work-related activities, until a final maintenance program is reached. These include activities for throwing (higher speed, lower resistance movements), pushing, pulling, lifting, and other types of resistive exercise, plyometrics and dynamic strength/stabilization training.
Occasionally, due to larger structural problems in the shoulder (rotator cuff tear, arthropathy, osteoarthritis, labral/biceps tearing, severe adhesive capsulitis) progress is limited and becomes static, with further improvements in function, flexibility and strength unlikely. Surgical consultation or dynamic splinting is recommended in the Discharge Summary.
