Managing the Stiff Shoulder

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Managing the Stiff Shoulder

• Noel Goodstadt, MPT, OCS, CSCS
• University of Delaware

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A Balance of Mobility
Stability
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Why is this important?

• Most patients treated for unidirectional shoulder
  instability are hypomobile in some other
  direction
• Treatment is directed at reducing the forced
  translation
• Imperative that we demonstrate our skill in
  treating managing these patients

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• Residual shoulder
• stiffness is the most
• frequent complication
• that occurs in the
• treatment process
• following shoulder
• surgery

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Normal Stiffness vs. Excessive Stiffness

• Variable dependent on several factors
• 1) Contralateral shoulder ROM
• 2) Instability Hx (TUBS vs. AMBRI)
• 3) Surgical Technique
• - Arthroscopic vs. Open
• - Anatomic vs. Non-anatomic
• 4) Functional level of patient

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Residual Stiffness

• lt 80 contralateral ROM is almost universally
  accepted as overly stiff
• An overly stiff joint not only limits function,
  but also may lead to early degeneration

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The First Step(post surgical procedure)

• Establish discuss Safe Zone or Set Points
  early (1st week)
• Based on patients Hx and physical exam, as well
  as, type of surgery (if performed), and surgeons
  perception based on operative findings and
  post-op exam under anasthesia

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Common Safe Zone

• ER ABD are generally limited
• ER lt 45o through week 4

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Common Safe Zone

• ABD lt 90o through week 4
• Thermal capsular shrinkage more limited due to
  uncertainty of the effect of mobilization

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An ounce of prevention is worth a pound of cure

• One of the keys to successfully treating shoulder
  patients is the ability to prevent excessive
  shoulder stiffness.
• Progress by achievement of milestones

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A Key to Success

• The probability of successful
• management is greatly increased
• if you recognize that the patient is
• prone to stiffness or becoming stiff
• early implement a plan for
• management immediately

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Early Detection

• Joint mobility assessment early
• Frequent PASSIVE assessment of the available ROM
  and the endfeel within the Safe Zone
• Assess the Scapulothoracic, AC, SC joints

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If you suspect the patient is developing or prone
to developing significant stiffness...

• Contact the patients orthopaedist
• Implement appropriate measures immediately
• Time is of the essence!

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Causes of Shoulder Stiffness

• Immobilization
• Lack of movement due to Pain / Inflammation
• Poor patient compliance in rehabilitation
• Synovitis
• Surgical Procedure
• RSD

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Immobilization

• You dont use it, you lose it
• Scarring can occur in the capsule, between soft
  tissue planes, and between the subscapularis and
  the scapula

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Priority 1

• Early passive ROM is your best means of reducing
  the likelihood of residual motion loss
• including joint mobilization in cardinal planes
  and combined planes
• Must be within the Safe Zone
• Safe and controlled active motion is also helpful

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Pain Inflammation

• Patients who experience shoulder pain
  inflammation tend to guard against motion,
  whether it is voluntary or reflexive
• Rx should be well within the patients tolerance,
  in other words DONT TORTURE the patient

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Pain Inflammation

• Mobility exercise therapy should be gentle,
  but frequent
• grade 1 2 mobs
• Duration of each activity / session should be
  long enough to promote tissue creep (I.e. Low
  Load, Long Duration)

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How long? Depends on the tissue the patients
comfort level minutes if possible
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Modalities

• Use modalities to prepare the patient for therapy
  and relieve potential discomfort from therapy
• More effective therapy sessions
• Psychological benefit

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Pain Control

• Joint Distraction (think of being forced to wear
  shoes that are too small all day long wouldnt
  you want the pressure taken off, at least for a
  little while?)
• COMMUNICATE - you must know what the patient is
  feeling (verbal non-verbal)

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Pain Inflammation

• Post-op hematoma? Try using heat, US, /or
  soft-tissue massage after 72 hours passes
• No when to slow things down and give the patient
  a break (2-7 days)

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Synovitis

• Inflammation of the joints synovial tissue
• Can occur from aggressive mobilization
• Occasionally occurs after arthroscopic Bankart
  repair with bioabsorbable tack with tissue
  shrinkage

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Synovitis

• Sudden increase in pain decrease in ROM for no
  apparent reason, generally around the 8 week
  point
• Slow things down (gentle ROM exercise as
  tolerated)
• Contact Orthopaedist, NSAIDS helpful

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Synovitis
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TIGHTNESS
CAPSULAR
Beware!
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Adhesive Capsulitis

• Tends to be of insidious onset
• May have started from shoulder pain, trauma,
  surgery
• Need to discuss with patient thoroughly to
  determine if there was a mechanism
• Self Limiting
• Avg. 18 months for resolution of shoulder
  stiffness
• Occurrence
• Common in patients with diabetes
• Females more than males
• Non-dominant arm
• Post surgical complication

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Adhesive Capsulitis

• 3 Phases
• Freezing, Frozen, Thawing
• Duration in each phase is not a set time
• Thorough history can help you to determine what
  phase the patient may be in
• Conservative treatment during the freezing phase
  is usually not successful
• Classical Capsular Pattern
• Limitation of ER gt flex/abd gt IR

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Patient Ownership

• Educate the patient that it
• is absolutely imperative that
• he or she recognizes that success is dependent
  on them taking the ownership in performing their
  rehabilitation as instructed

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AAROM

• Codmans Pendulum
• Wand ex (T-bar, L-bar)
• Table Wall stretches
• Pulley Systems
• UBE
• Low load, long duration (tubing)

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Self Stretch - Static
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Stretching with Equipment
UBE
Gravitron
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Low Load, Long Duration
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Aquatic Therapy

• Relaxes patient
• Reduces pain
• Safe environment for mobilization
• Try manual techniques in H2O

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Contract-Relax / Hold-Relax

• Flexion / Extension
• ER / IR (move into HABD as well)
• ER / IR in HADD

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Capsular Stretching
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Capsular Stretching
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Joint Mobilization

• Start off w/ Grades I / II if ROM is limited by
  pain, progress as tolerated
• Low Load, Long Duration capsular stretches
• Concentrate on tight structures, generally
  anterior or posterior capsule

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Distraction

• Relieves Pain
• General mobility
• Increase elevation
• Caudal Lateral

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Distraction
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Inferior Glide

• Increases elevation
• Stretches the inferior capsule
• When performed in 90o abduction increases
  elevation gt 90o

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ER with Abduction Inferior Glide

• Stretches the anterior inferior capsule
• Improves external rotation and elevation

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Anterior Glide

• Stretches the anterior capsule
• Improves external rotation

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Anterior Glide (Prone) w/ ER Distraction

• Stretches the anterior capsule
• Stretches creep in the inferior capsule
• Improves external rotation elevation

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Posterior Glide

• Stretches in posterior capsule
• Improves elevation internal rotation
• Can be performed w/ rotation distraction

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Sometimes Theyre Too Loose

• gt 25 ER at first post-op visit or gt 45 ER at 2
  weeks and was treated with capsular shift or
  shrinkage procedure (AMBRI, Recurrent)
• Slow things down prolonging immobilization or
  restricting mobility

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Cannot externally rotate past neutral at initial
evaluation ?

• Prone to residual stiffness
• Usually require orthopaedic intervention
• Usually have had capsular shift or non-anatomic
  repair

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Patients who have lt 25o ER or lt 45o Abd at 2
weeks need to speed-up...

• Most patients that are a little behind schedule
  reach full ROM by 12 weeks
• May need to shorten period of immobilization
• Expand Safe Zone

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Patients with lt 60o ER or lt 150o FE at 3 months
post-op may require intervention

• Steroid Injection
• Manipulation (UA)
• Hydraulic Distension
• Arthroscopic Release
• Open Release

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Surgical Intervention

• Manipulation Under Anasthesia (MUA)
• Cold Distension
• Arthroscopic Capsular Release

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Arthroscopic Capsular Release
Before
After
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Arthroscopic Capsular Release
After
Before
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Post Surgical Intervention

• Rehab will be performed daily for first 2 weeks
  then frequency decreases to 3x/week
• Manual stretching needs to be aggressive and
  followed up with self stretching
• HEP frequently each day
• After day 1 will see a loss of motion, but each
  treatment should show progress in gaining back
  what was achieved on the OR table

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Shoulder Arthroplasty

• Types
• Hemiarthroplasty
• Total Shoulder Arthroplasty
• Reverse TSA

• Primary indications
• Osteoarthritis severe pain restricted ROM
• Typical Complaints
• night pain
• pain at rest
• pain with ADLs

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Shoulder Arthroplasty

• Other indications
• RA
• Arthritis of Dislocation
• premature degeneration after instability repair
• AVN
• Arthropathy
• Acute Fractures
• Posttraumatic Arthritis
• Reverse TSA
• Irrepairable RC tear

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Physical Exam Pre-TSA

• A/PROM generally limited
• Compensations for elevation
• shrug sign
• Limitation of ER is very sensitive in determining
  the degree of GH restriction
• Tender along the joint line

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TSA

• Visualization
• Subscapularis takedown most common approach
• may include anterior-inferior capsular release
• Fixation
• cemented or bone ingrowth prosthesis
• sutures and/or sutures with anchors
• Surgery
• protect the subscapularis repair
• protect any RC tear that is also repaired

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Rehabilitation after arthroplasty

• Overall goals are pain relief and improvement in
  function
• Focus on limiting postoperative contractures
• Increase ROM to functional levels
• Treatment similar to RC Repair and Bankart Repair
• Protect the subscapularis and anterior capsule
  early on
• Protect supra/infraspinatus if RC tear involved
• Progress from protection to RC and deltoid
  strengthening
• Early on work on scapulohumeral rhythm for
  proximal stabililty

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Rehabilitation after arthroplasty

• First 6 weeks
• Maintain glenohumeral flexibility with AAROM and
  PROM
• Limited to no gt 1 pound for lifting
• Avoid NSAIDS
• Formal RC strengthening held for 12 weeks to
  ensure healing
• Lynch et al., JBJS 2007

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Rehabilitation after TSA

• Categories of Rehabilitation
• Good RC/deltoid
• Poor or repaired RC deltoid
• Limited goals

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Rehabilitation Post - TSA

• Boardman et al., 2001
• 81 shoulder post TSA
• Studied the benefit of a home program of
  rehabilitation
• ROM
• Pre-op ER 21 Elevation 84
• Intra-op ER 41 Elevation 144
• Post-op ER 48 Elevation 136

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Meta-analysis TSA vs. Hemiarthroplasty

• Bryant et al., JBJS 2005
• Results of the review, found only one study that
  met the criteria and 3 other presentations from
  professional conferences
• Published study by Gartsman et al.
• TSA group had significantly less pain and greater
  internal rotation
• No difference with respect to active elevation
  and external rotation
• TSA after 2 year follow-up
• provides more consistent improvement in function
  than hemiarthroplasty for patients with primary
  OA
• Longer term follow-up is necessary due to
  continued degeneration of the glenoid in
  hemiarthroplasty and glenoid loosening

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Reverse TSA

• Salvage Procedure
• Failed hemiarthroplastys
• Irrepairable rotator cuff tear with severe GH OA
• Over 70 y.o. with poor function and severe pain
  related to cuff deficiency.
• Rockwood, 2007
• Complication rates 13 to 50
• Deltoid alone powers shoulder function
• Sometimes shoulder function can be dramatic
  achieving overhead position

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Post-op Rehab

• Frankle et al., JBJS 2006
• Immobilized 6 weeks
• After 6 weeks
• Supine AAROM to AROM against gravity
• Resistance exercise after 12 weeks