The addition of multi-planar mobilizations to target the ...
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The addition of multi-planar mobilizations to target the rotator cuff interval and capsuloligamentous complex in a middle aged female with adhesive capsulitis: a case study Author: Roma Rana PT, DPT, Alina Hedaya PT, DPT, OCS, Cert MDT, Michele Beltram PT, DPT, OCS Select Medical Orthopaedic Residency Program Background: Adhesive capsulitis is a common shoulder dysfunction characterized by an exaggerated and sustained inflammatory and fibrotic response of the capsuloligamentous complex (CLC) and rotator cuff interval (RCI) 2-6 . The CLC and RCI provide an anterior/superior hammock restraint into ER at 0 degrees abduction and inferior translation 6 . Clinically, patients present with ROM loss of greater than 25% in at least 2 planes and passive ER loss that is greater than 50% of the unaffected shoulder or less than 30 degrees of ER 6 . Recommended treatment options for low irritability include end range, increased duration stretching, high grade mobilizations with sustained holds and high resistance end range strengthening. 6 Purpose: The purpose of this study is to demonstrate the benefits of multi-planar mobilizations to target the RCI and CLC for patients with adhesive capsulitis. Case Description: A 46-year old female with four month history of right shoulder pain referred from her orthopedist with unremarkable past medical history. Primary functional limitations were reaching overhead to shower, behind her back to dress, sleeping disturbances with limitation in shoulder ROM, strength, Apley’s IR/ER, GH joint mobility in multiple planes. Interventions provided included posterior and inferior glide grade II-III glenohumeral and scapulothoracic joint mobilizations, capsular self-stretching, and active-assist range of motion shoulder flexion including pulleys and wall slides, and concentric scapular retractions were performed. At 16 visits, QuickDASH and functional movements to dress plateaued. Combining GH distraction, adduction and IR in side-lying to target the RCI and posterior superior capsuloligamentous complex to regain functional ER/IR were incorporated for the next 10 visits with multi-planar mobilizations. Progression included long duration end range stretching sleeper’s stretch, eccentric rotator cuff strengthening and functional D2 pattern for strengthening. Discussion: At visit 16, patient exhibited plateau in shoulder flexion A/PROM, functional Apley’s IR/ER and ability to dress with uni-planar GH mobilizations. Therefore, multi-planar movement combining end range GH distraction extension, adduction and internal rotation in side-lying were incorporated to target the RCI and CLC. With the addition of multi-planar end range mobilizations, this patient demonstrated a significant improvement in shoulder flexion and abduction A/PROM, decreased disability on the QuickDASH, and Apley’s IR/ER in regards to washing her back, dressing and sleeping. Conclusion: This case report suggests that incorporating multi-planar movement to target the RCI and CLC may be beneficial in treating patients with adhesive capsulitis with a low irritability who are impaired by shoulder mobility for activities of daily living . Initial Visit 16 Discharge Shoulder flexion right A/PROM (degrees) 80/90 115/135 140/150 Shoulder abduction right A/PROM (degrees) 45/65 85/95 118/120 Apley's IR/ER (right) Unable C5, buttocks C7, L5 Apley's IR/ER (left) C7, T6 C7, T6 C7, T6 References: 1. Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. Journal of Bone and Joint Surgery Br. 2007;89(7): 928-932. 2. Bunker TD, reilly J, Baird KS, Hamblin DL. Expression of growth factors, cytokines and matrix metalloproteinases in frozen shoulder. Journal of Bone and Joint Surgery Br. 2000;82(5): 768-773. 3. Rodeo SA, Hannafin JA, Tom J, Warren TF, Wickiewicz TL. Immuolocalization of cytokines and their receptors in adhesive capsulitis of the shoulder. Journal of Orthopedic Res. 1997;15(3): 427-436 4. Hutchinson JW, Tierney CM, Parsons SL, Davis TR. Dupuytren’s disease and frozen shoulder induced by treatment with a matrix metalloproteinase inhibitor. Journal of Bone and Joint Surgery Br. 1998;80(5): 907-908 5. Mullet H, Byrne D, Colville J. Adhesive capsulitis: human fibroblast response o shoulder joint aspirate from patients with stage II disease. Journal of Shoulder Elbow Surgery. 2007;16(3): 290-294. Epub 2007 Jan. 18. 6. Ellenbecker T, Manske R, Kelley M (2016). The shoulder: physical therapy patient management using current evidence. Current Concepts of Orthopaedic Physical Therapy (4 th edition, pp 45-53). Retrieved September 26 th , 2018. 7.Ogul et al. Anatomy, variants, and pathologies of the superior glenohumeral ligament: magnetic resonance imaging with three-dimensional volumetric interpolated breath-hold examination sequence and conventional magnetic resonance arthrography. Korean Journal of Radiology. 2014 Jul-Aug; 15(4): 508-522.
Transcript of The addition of multi-planar mobilizations to target the ...
The addition of multi-planar mobilizations to target the rotator cuff interval and capsuloligamentous complex in a middle aged female with adhesive capsulitis: a case study
Author: Roma Rana PT, DPT, Alina Hedaya PT, DPT, OCS, Cert MDT, Michele Beltram PT, DPT, OCSSelect Medical Orthopaedic Residency Program
Background: Adhesive capsulitis isa common shoulder dysfunctioncharacterized by an exaggerated andsustained inflammatory and fibroticresponse of the capsuloligamentouscomplex (CLC) and rotator cuffinterval (RCI)2-6. The CLC and RCIprovide an anterior/superiorhammock restraint into ER at 0degrees abduction and inferiortranslation6. Clinically, patientspresent with ROM loss of greaterthan 25% in at least 2 planes andpassive ER loss that is greater than50% of the unaffected shoulder orless than 30 degrees of ER6.Recommended treatment options forlow irritability include end range,increased duration stretching, highgrade mobilizations with sustainedholds and high resistance end rangestrengthening. 6
Purpose: The purpose of this studyis to demonstrate the benefits ofmulti-planar mobilizations to targetthe RCI and CLC for patients withadhesive capsulitis.
Case Description: A 46-year old female with four month history of right shoulderpain referred from her orthopedist with unremarkable past medical history.Primary functional limitations were reaching overhead to shower, behind her back todress, sleeping disturbances with limitation in shoulder ROM, strength, Apley’sIR/ER, GH joint mobility in multiple planes. Interventions provided includedposterior and inferior glide grade II-III glenohumeral and scapulothoracic jointmobilizations, capsular self-stretching, and active-assist range of motion shoulderflexion including pulleys and wall slides, and concentric scapular retractions wereperformed. At 16 visits, QuickDASH and functional movements to dress plateaued.Combining GH distraction, adduction and IR in side-lying to target the RCI andposterior superior capsuloligamentous complex to regain functional ER/IR wereincorporated for the next 10 visits with multi-planar mobilizations. Progressionincluded long duration end range stretching sleeper’s stretch, eccentric rotator cuffstrengthening and functional D2 pattern for strengthening.
Discussion: At visit 16, patient exhibitedplateau in shoulder flexion A/PROM,functional Apley’s IR/ER and ability to dresswith uni-planar GH mobilizations. Therefore,multi-planar movement combining endrange GH distraction extension, adductionand internal rotation in side-lying wereincorporated to target the RCI and CLC. Withthe addition of multi-planar end rangemobilizations, this patient demonstrated asignificant improvement in shoulder flexionand abduction A/PROM, decreased disabilityon the QuickDASH, and Apley’s IR/ER inregards to washing her back, dressing andsleeping.
Conclusion: This case report suggests thatincorporating multi-planar movement totarget the RCI and CLC may be beneficial intreating patients with adhesive capsulitis witha low irritability who are impaired by shouldermobility for activities of daily living .
Initial Visit 16 Discharge
Shoulder flexion right
A/PROM (degrees)
80/90 115/135 140/150
Shoulder abduction right
A/PROM (degrees)
45/65 85/95 118/120
Apley's IR/ER (right) Unable C5, buttocks C7, L5
Apley's IR/ER (left) C7, T6 C7, T6 C7, T6
References: 1. Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. Journal of Bone and Joint Surgery Br. 2007;89(7): 928-932. 2. Bunker TD, reilly J, Baird KS, Hamblin DL. Expression of growth factors, cytokines and matrix metalloproteinases in frozen shoulder. Journal of Bone and Joint Surgery Br. 2000;82(5): 768-773.3. Rodeo SA, Hannafin JA, Tom J, Warren TF, Wickiewicz TL. Immuolocalization of cytokines and their receptors in adhesive capsulitis of the shoulder. Journal of Orthopedic Res. 1997;15(3): 427-4364. Hutchinson JW, Tierney CM, Parsons SL, Davis TR. Dupuytren’s disease and frozen shoulder induced by treatment with a matrix metalloproteinase inhibitor. Journal of Bone and Joint Surgery Br. 1998;80(5): 907-9085. Mullet H, Byrne D, Colville J. Adhesive capsulitis: human fibroblast response o shoulder joint aspirate from patients with stage II disease. Journal of Shoulder Elbow Surgery. 2007;16(3): 290-294. Epub 2007 Jan. 18.6. Ellenbecker T, Manske R, Kelley M (2016). The shoulder: physical therapy patient management using current evidence. Current Concepts of Orthopaedic Physical Therapy (4th edition, pp 45-53). Retrieved September 26th, 2018.7.Ogul et al. Anatomy, variants, and pathologies of the superior glenohumeral ligament: magnetic resonance imaging with three-dimensional volumetric interpolated breath-hold examination sequence and conventional magnetic resonance arthrography. Korean Journal of Radiology. 2014 Jul-Aug; 15(4): 508-522.
