[ case report ]

LIRIOS DUEÑAS, PT, PhD1 • MERCÈ BALASCH-BERNAT, PT, PhD1 • MARTA AGUILAR-RODRÍGUEZ, PT, PhD1
FILIP STRUYF, PT, PhD2 • MIRA MEEUS, PT, PhD2-4 • ENRIQUE LLUCH, PT, PhD1,4,5

A Manual Therapy and Home

Stretching Program in Patients With
Primary Frozen Shoulder Contracture
Syndrome: A Case Series
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F
rozen shoulder is a common musculoskeletal disorder refuted,3,53 the term frozen shoulder con-
characterized by a progressive loss of both active and passive tracture syndrome (FSCS) was recently
suggested in order to describe the condi-
mobility of the glenohumeral joint.39,50,57 This restriction has
tion more appropriately.31
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

been attributed to numerous pathological changes, including Traditionally, the natural history of
thickening and fibrosis of the rotator interval, coracohumeral ligament FSCS was proposed to be self-limiting
and anterior-inferior capsule (axillary re- deficits in external and internal rotation and follow 3 phases (painful, stiff, and
cess), neovascularity in the rotator inter- have been shown in patients with frozen recovery), leading to full recovery with-
val, or reduced joint volume.31 In addition shoulder.32 As evidence for capsular ad- out treatment.14,44 However, this assump-
to motion limitations, muscle strength hesions to the humeral head has been tion is not always supported, as a recent
systematic review reported early im-
UUBACKGROUND: Manual therapy has been ment. Additionally, 4 of 11 patients showed pain provements in shoulder range of motion
demonstrated to reduce pain and improve function improvements that exceeded the minimal clinically (ROM) and function slowing down with
Journal of Orthopaedic & Sports Physical Therapy®

in patients with frozen shoulder contracture syn- important difference (MCID) on the visual analog time, with prolonged limitations possible
drome (FSCS), but no evidence exists to support scale postintervention, and 8 of 11 showed pain and lasting for multiple years.60
one form of manual therapy over another. This improvements at 6 and 9 months. Moreover, 7 of
case series describes both short- and long-term Multiple physical therapy interven-
11 patients showed improvements in Disabilities of
outcomes after a manual therapy program and the Arm, Shoulder and Hand (DASH) questionnaire tions, including manual therapy tech-
home stretching exercises based on specific im- scores exceeding the MCID postintervention and niques, have been investigated for this
pairments in shoulder mobility and level of tissue at 6 months, and 8 of 11 exceeded the MCID at 9 condition. Manual therapy techniques
irritability in patients with FSCS. months. are applied with the purpose of restor-
UUCASE DESCRIPTION: Eleven patients with UUDISCUSSION: Clinically meaningful changes ing normal tissue extensibility of the
primary FSCS were treated with an individually in shoulder pain and disability, ROM, or muscle shoulder capsule and improving ROM.
tailored, multimodal manual therapy approach strength were observed in 11 patients with primary
once weekly for 12 visits, coupled with home Indeed, several studies have shown ben-
FSCS treated with an individually tailored approach
stretching exercises once a day, 5 days per week. eficial effects on pain and mobility in
of both manual therapy techniques and stretching
Pain, disability, range of motion (ROM), and
exercises, accounting for tissue irritability.
patients with FSCS after the application
muscle strength of the affected shoulder were of angular mobilizations,10 Mulligan’s
assessed at baseline, posttreatment, at 6 months, UULEVEL OF EVIDENCE: Therapy, level 5.
mobilization-with-movement (MWM)
and at 9 months. J Orthop Sports Phys Ther 2019;49(3):192-201.
techniques,9,62,63 and Maitland tech-
UUOUTCOMES: Significant improvements in
Epub 18 Jan 2019. doi:10.2519/jospt.2019.8194
UUKEY WORDS: case series, frozen shoulder,
niques, including high-grade, low-grade,
self-reported pain, disability, shoulder ROM,
and strength were reported following treat- manipulation, mobilization, pain end-range, and midrange passive mobili-
zation techniques.12,21,29,55,56,62,63 However,

1
Department of Physical Therapy, University of Valencia, Valencia, Spain. 2Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health
Sciences, University of Antwerp, Antwerp, Belgium. 3Department of Rehabilitation and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Ghent,
Belgium. 4Pain in Motion International Research Group, Brussels, Belgium. 5Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education
and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium. This case series received approval from the Institutional Review Board at the University of Valencia
(H1432625002427). The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject
matter or materials discussed in the article. Address correspondence to Dr Lirios Dueñas, Department of Physical Therapy, University of Valencia, Carrer de Gascó Oliag 5,
46010 Valencia, Spain. E-mail: [email protected] t Copyright ©2019 Journal of Orthopaedic & Sports Physical Therapy®

192 | march 2019 | volume 49 | number 3 | journal of orthopaedic & sports physical therapy
 according to evidence-based recommen- techniques focused on internal/external The inclusion criteria were FSCS not
dations8,41 and clinical practice guide- ROM at different ranges of abduction associated with a systemic condition or
lines,24 there is no evidence to support and a home stretching exercise program history of injury,64 a loss of passive ex-
one form of manual therapy over another. in patients with FSCS. Perceived tissue ternal rotation greater than 50% when
In addition, the optimal dose and timing irritability primarily guided the physical compared to the uninvolved shoulder
of manual therapy treatments have not therapists’ clinical-reasoning approach. or less than 45° of external rotation,24,33
been established. ROM loss of greater than 25% in at least
Prior research in FSCS applied man- CASE DESCRIPTION 2 movement planes in comparison to
ual therapy techniques, mainly using a the uninvolved shoulder,24 and pain and
protocol-based approach.41 Individual- Patients restricted movement present and reach-

E
ized approaches are believed to address leven consecutive patients with ing a plateau or worsening for at least 1
the patient’s needs to a greater extent.5 a diagnosis of primary FSCS were month.24
However, the potential benefits of an in- referred by their primary care physi- Patients were excluded if they had
dividualized treatment approach tailored cian to the Department of Physical Ther- any of the following: previous shoulder
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to the individual patient with FSCS are apy at the University of Valencia (Spain) surgery; partial- or full-thickness rotator
unknown. between September 2015 and June 2016 cuff tear on ultrasonography or magnetic
Clinical practice guidelines have high- and screened for eligibility. A patient flow resonance imaging; FSCS secondary to
lighted the importance of considering the diagram for the selection process is pro- other causes (including inflammatory or
level of tissue irritability when managing vided in FIGURE 1. infectious arthritis, stroke, or fracture);
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

patients with FSCS.24 Three levels of ir-

ritability (high, moderate, and low) have Assessed for eligibility, n = 30
been proposed by expert consensus, ac- • Patients referred by their primary care
cording to the intensity and frequency of physician
• Diagnosis of FSCS
pain, behavior of active and passive mo-
• Pain for at least 1 mo, having reached a
bility, and the level of disability reported plateau or worsened
by the patient.24 Clinicians are encour-
aged to adapt their treatment strategies
for FSCS to the stage of tissue irritabil- Interview by physical therapist
Journal of Orthopaedic & Sports Physical Therapy®

ity to adjust the mobilization direction Excluded, n = 10

and to place the appropriate physical • Diagnosis of secondary FSCS
• Shoulder surgery
stress on the tissue at each stage.23 To re- • Other diseases of the shoulder
store shoulder mobility in patients with
FSCS, an emphasis on shoulder rotation Evaluated by physical therapist
Excluded, n = 9
over pushing the shoulder into painful • ROM loss <25% in at least 2 movement
and restricted flexion ranges has been planes
proposed.8 Forced flexion may cause • ROM loss <50% of PER compared to
the uninvolved shoulder or more than
greater periarticular tissue damage and 45° of PER
inflammation and increase the patient’s Met eligibility criteria, n = 11
• ROM loss ≥25% in at least 2 movement
pain.8 According to this concept, manual planes
therapy interventions are guided accord- • ROM loss ≥50% of PER compared to
ing to the specific soft tissue restrictions the uninvolved shoulder or less than
found during the assessment of passive 45° of PER
shoulder internal and external rotation.8
To our knowledge, only 1 case study7 has
previously described this biomechanical Posttreatment, 6 mo, and 9 mo, n = 11
• The adherence rate for manual
approach, whereas the concept of the physical therapy sessions was 100%.
level of tissue irritability has not been re- All patients completed all visits. Home
ported when treating patients with FSCS. stretching program adherence was
The purpose of this case series was higher than 75%
to describe both short- and long-term
outcomes after the application of a mul- FIGURE 1. Patient flow diagram. Abbreviations: FSCS, frozen shoulder contracture syndrome; PER, passive external
rotation; ROM, range of motion.
timodal approach of manual therapy

journal of orthopaedic & sports physical therapy | volume 49 | number 3 | march 2019 | 193
 [ case report ]
calcification, demonstrated by simple ra- Evaluation Procedure ity inclinometer (Dr Rippstein, Zurich,
diography or ultrasonography; disorders Assessment took place before the inter- Switzerland), following previous guide-
to the biceps tendon or acromioclavicular vention (baseline), immediately after lines.26-28,40 The Plurimeter-V measures
joint; or presence of medical or psycholog- the 3-month intervention period (post- ROM with a 1° interval13 and has a stan-
ical conditions, including cancer, rheuma- treatment), and at 3 and 6 months after dard error of measurement ranging from
toid arthritis, or major depression. the intervention period (6 months and 9 1.7° to 5.2°.59
All patients were allowed to continue months from baseline, respectively). All Active ROM and active ROM with
their usual medication. Prior to inclu- patients completed a standard medical overpressure for shoulder flexion and ab-
sion, none of the patients had received a history questionnaire, including sociode- duction of each patient’s affected shoul-
corticosteroid injection in their affected mographic data and questions related to der were measured with the patient in
shoulder or reported satisfactory results medication use. Examination included a relaxed standing position.26 Patients
(progress in mobility, pain, or func- measures of shoulder pain and disability, were instructed to move the shoulder to
tion) from previous physical therapy or active ROM and active ROM with over- maximum flexion and abduction until
any treatment applied by their general pressure, and muscle strength. Adverse pain or limitation of movement (which-
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practitioner. Physical therapy treatment effects were recorded using open-ended ever came first) while maintaining the
included analgesic modalities (eg, trans- questioning.48 An adverse effect was arm in a strict sagittal or frontal plane,
cutaneous electrical nerve stimulation, defined as any undesirable experience respectively, avoiding excessive compen-
cryotherapy), general exercises, and during follow-up leading to the need for sation from the thoracic or lumbar spine.
manual therapy techniques. additional contact with the health care The inclinometer was attached to the
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

All patients who met the inclusion cri- system (physical therapist, general prac- proximal upper arm with 2 Velcro (VIL
teria provided written consent for partici- titioner, or hospital). Ltd, London, UK) straps to ensure con-
pation, and their rights were protected. sistent alignment of the inclinometer for
This study was approved by the Institu- Outcome Measures shoulder flexion and abduction over the
tional Review Board at the University of Shoulder Pain and Disability Shoulder biceps brachii and middle deltoid mus-
Valencia (Spain) (H1432625002427). pain was assessed using a 100-mm vi- cles, respectively. To test active ROM
sual analog scale (VAS), ranging from 0 with overpressure, the examiner applied
Physical Therapists (“no pain”) to 100 (“the worst imaginable overpressure at the end of active shoulder
One physical therapist (E.L.G.) with 20 pain”). The VAS assessment in this study flexion and abduction while stabilizing
Journal of Orthopaedic & Sports Physical Therapy®

years of clinical experience performed all considered average patient pain over the scapula.
of the baseline and follow-up assessment the 24 hours prior to assessment.17 The In addition, scapular upward rotation
measurements. The physical therapist minimal clinically important difference during shoulder abduction was mea-
was blinded to the results of the ear- (MCID) for the VAS is estimated to be sured using the Plurimeter-V inclinom-
lier measurements. A second physical 30 mm.30 eter following the procedure described
therapist (M.B.B.), board certified in or- Shoulder disability was measured with by Watson et al.59 The inclinometer was
thopaedic physical therapy and with 10 the Spanish version of the self-adminis- manually positioned along the spine
years of clinical experience, conducted tered Disabilities of the Arm, Shoulder and to the scapula to measure the degree of
all the manual therapy techniques and Hand (DASH) questionnaire.19 The DASH scapular upward rotation at the end of
was blinded to the assessment outcomes. comprises 30 items and 2 optional sections shoulder abduction.
Prior to the study, the physical therapist related to the impact of pathology on work Finally, active ROM and active ROM
who performed the intervention (M.B.B.) and sports, and is scored from 1 to 5, with with overpressure for shoulder external
underwent a 3-hour session led by 1 of increasing values representing greater se- rotation were measured in supine, from
the authors (E.L.G.) for specific training verity of symptoms.36 The total score (30- a position of 0° of shoulder abduction
in the application of the interventions. 150) was then transformed to a scale from and 90° of elbow flexion. The inclinom-
During this training session, the treat- 0 to 100 (worst score). The Spanish ver- eter was attached to the dorsal surface
ing physical therapist was instructed to sion of the DASH has shown high internal of the distal forearm, and patients were
perform all manual therapy techniques consistency (Cronbach α = .96), excellent first instructed to move the forearm lat-
accurately, including pilot treatment on test-retest reliability (r = 0.96) and con- erally into shoulder external rotation. To
2 healthy individuals. In addition, this struct and criterion validity, and excellent test active ROM with overpressure, the
physical therapist was provided with a responsiveness to treatment.19 The MCID examiner applied overpressure at the
treatment booklet outlining the treat- for the DASH is 10.2 points.45 end of active shoulder external rotation
ment techniques and details of each in- Shoulder ROM Shoulder ROM was while stabilizing the anterior aspect of
tervention included in the study. measured using a Plurimeter-V grav- the shoulder.

194 | march 2019 | volume 49 | number 3 | journal of orthopaedic & sports physical therapy
 Measurements of shoulder ROM in For each muscle strength test, 3 rep- therapy program.8 In addition, if hand-
a seated position with the trunk upright etitions were performed, with a 30-sec- behind-back and/or flexion ROM were
have demonstrated good reliability and ond rest period between measurements, specifically limited, MWM techniques
validity.26,27 and the mean was used for analysis. Iso- were performed (APPENDIX A, available at
Shoulder Muscle Strength Muscle metric strength testing with a handheld www.jospt.org).20 For instance, if a pa-
strength was measured using a portable dynamometer has shown acceptable reli- tient presented with limitation in exter-
handheld dynamometer (Manual Muscle ability for clinical use.4 nal rotation at 90° of abduction, then a
Tester; Lafayette Instrument Company, superior/inferior glenohumeral glide was
Lafayette, IN). Shoulder strength mea- Intervention performed.6
surements were performed in sitting Patients received a 12-session treatment Passive oscillatory mobilizations (eg,
position using the “make” procedure.49 program delivered in 60-minute sessions, Maitland mobilizations)34 were applied as
Patients were instructed to push in the scheduled once a week, over a period of 5 bouts of 1 minute of joint mobilization
desired direction while maintaining the 12 weeks. The intervention program (grades I-IV), and MWM techniques as
trunk in a stable position and exert as consisted of a multimodal approach of 3 sets of 10 repetitions. Detailed descrip-
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much force as possible against the dyna- manual therapy techniques, based on tis- tions of the manual therapy techniques
mometer during 6 seconds.49 sue irritability level24 and specific impair- comprising the treatment program are
For shoulder flexion, patients were ments in shoulder mobility (eg, internal/ provided in APPENDIX A. The techniques
positioned in 90° of elevation in the external passive ROM at different levels were prioritized based on shoulder ROM
scapular plane, simulating the full-can of abduction).8 Regarding tissue irritabil- limitations.
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

test position. The dynamometer was ity level, low-grade, low- to high-grade, or Patients performed home stretching
placed on the dorsal aspect of the dis- high-grade mobilizations were applied for exercises during the treatment period
tal forearm.18 To test shoulder external high, moderate, or low irritability, respec- once a day, 5 days per week, tailored to
rotation, patients were positioned with tively (TABLE 1).23 For instance, in patients individual shoulder ROM limitation
the shoulder in 0° of abduction and me- with high irritability, low-grade, passive, and tissue irritability level, as specified
dially rotated 45°, the elbow flexed to oscillatory mobilization manual tech- in APPENDIX B (available at www.jospt.
90°, and the forearm in its mid ROM, niques (eg, Maitland mobilization grades org). Patients were instructed to adapt
between supination and pronation. The I-II) and low-intensity and short-dura- the intensity and duration of the stretch-
dynamometer was placed on the dorsal tion (1-5 seconds) pain-free stretching ing exercises according to their level of
Journal of Orthopaedic & Sports Physical Therapy®

surface of the distal forearm just proxi- exercises (0/10 on a numeric pain-rating irritability. Patients with high irritabil-
mal to the ulnar styloid process.25 To test scale) were performed to reduce pain and ity performed short-duration, pain-free
shoulder internal rotation, the shoulder decrease muscle guarding.23 (5 bouts of 1 to 5 seconds) stretching,
was positioned in 0° of abduction, the Concerning shoulder ROM limita- patients with moderate irritability per-
elbow was flexed to 90°, and the forearm tions, internal and external active rota- formed short-duration (5 bouts of 5 to
was in its mid ROM, between supina- tion with overpressure testing at different 15 seconds) stretching, and patients with
tion and pronation. The dynamometer degrees of shoulder abduction guided the low irritability performed increased-du-
was placed on the ventral surface of the treating physical therapists in determin- ration stretches, with allowance for some
distal forearm. ing the direction and focus of the manual pain or discomfort.23

Irritability Classification and Treatment Strategies

TABLE 1
Based on Irritability Level*

High Irritability Moderate Irritability Low Irritability

History and examination findings High pain (≥7/10) Moderate pain (4-6/10) Low pain (≤3/10)
Consistent night or resting pain Intermittent night or resting pain No resting or night pain
Pain prior to end of ROM Pain at end of ROM Minimal pain at end ROM with overpressure
AROM less than PROM, secondary to pain AROM similar to PROM AROM same as PROM
ROM/stretch Short-duration (1-5 seconds), pain-free passive Short-duration (5-15 seconds) passive AAROM End range/overpressure, increased duration,
AAROM to AROM cyclic loading
Manual techniques Low-grade mobilization (grades I-II) Low- to high-grade mobilization (grades I-IV) High-grade mobilization, sustained hold
(grades III-IV)
Abbreviations: AAROM, active assisted range of motion; AROM, active range of motion; PROM, passive range of motion; ROM, range of motion.
*Adapted with permission from Kelley et al.23

journal of orthopaedic & sports physical therapy | volume 49 | number 3 | march 2019 | 195
 [ case report ]
Adherence to the home stretching pro- strength (shoulder flexion, internal and 6, improved their VAS score at posttreat-
gram was monitored using an individual external rotation). The glenohumeral ment. Changes in pain were maintained or
treatment diary, where the date and dura- contribution to total active shoulder even improved at 6 and 9 months in 9 of
tion of each home session were recorded.37 abduction was calculated by subtract- 11 patients.
Prior to each treatment session, shoul- ing scapular upward rotation from total Seven of 11 patients showed improve-
der ROM limitations8 and level of per- shoulder abduction ROM and named ments in DASH scores exceeding the
ceived tissue irritability were assessed by “isolated glenohumeral active abduction.” MCID at posttreatment and at 6 months,
the treating physical therapist (TABLE 1).22 and 9 of 11 patients exceeded the MCID
Consequently, the most suitable manual OUTCOMES at 9 months. All patients, except patient
therapy techniques for that treatment 2, improved their DASH score at post-

T
session, and the home stretching pro- he characteristics of partici- treatment (FIGURE 2).
gram to be used until the next planned pants, including baseline demo-
session, were chosen. graphics, are shown in TABLE 2. The Shoulder ROM
Treatment was progressed based on study group included 11 patients with Nine of 11 patients improved their active
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reassessment of shoulder ROM limita- FSCS (3 men, 8 women; mean ± SD age, shoulder flexion and active shoulder flex-
tions and perceived tissue irritability in 52.6 ± 5.3 years; body mass index, 23.1 ion with overpressure at posttreatment.
subsequent sessions. In addition, to en- ± 3.6 kg/m2). The dominant shoulder This movement continued improving at
sure that manual therapy techniques and was affected in 8 cases, and 3 patients 6 months in all patients except patient 4.
the home stretching program were well had type 2 diabetes mellitus. All patients Improvements were noted in active
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tolerated, the intensity and duration of were treated for 12 sessions. Treatment shoulder abduction and active shoulder
the manual therapy techniques were con- was initiated a mean of 12 ± 7.8 months abduction with overpressure in 9 of 11 pa-
tinuously adapted within and between after the initial onset of symptoms. The tients. Active shoulder abduction contin-
sessions, according to patient response adherence rate for manual physical ther- ued improving at 6 months in all patients
and level of irritability. A clinical-reason- apy sessions was 100%. Home stretching except patient 2, and 4 patients showed
ing diagram describing how a technique program adherence was good (defined a slightly decreased ROM at 9 months.
was progressed or regressed based on pa- as fulfilling more than 75% of sessions). Active shoulder abduction with overpres-
tient response is provided in APPENDIX C No adverse events or side effects were re- sure continued improving at 6 months in
(available at www.jospt.org). ported by any of the treated patients. Re- all patients except patient 8, and 5 pa-
Journal of Orthopaedic & Sports Physical Therapy®

sults of the different outcome measures tients showed a slightly decreased ROM
Data Analysis for each patient and each measurement at 9 months.
Data from 11 patients were analyzed time are summarized in TABLES 3 and 4. Seven patients improved their active
through descriptive statistics. Outcome shoulder external rotation at posttreat-
measures were VAS and DASH scores, Shoulder Pain and Disability ment. Similar results were obtained for
shoulder ROM (active and active with Four of 11 patients showed pain improve- the follow-up measurements. Eight of 11
overpressure shoulder flexion, abduc- ments exceeding the MCID on the VAS at patients showed higher active shoulder
tion, and external rotation, and upward posttreatment, and 8 of 11 patients did so at external rotation with overpressure at
scapular rotation), and shoulder muscle 6 and 9 months. All patients, except patient posttreatment, and 9 continued improv-

TABLE 2 Participant Demographics and Baseline Characteristics

Patient
1 2 3 4 5 6 7 8 9 10 11
Sex Female Female Female Female Female Male Female Male Female Female Male
Age, y 43 55 50 56 60 49 57 59 52 51 47
BMI, kg/m2 20.1 25.5 17.9 18.3 28.9 24.0 22.4 28.4 23.2 21.6 24.2
Affected side Right (D) Left (D) Right (D) Right (D) Right (D) Left (ND) Left (D) Right (D) Left (ND) Right (D) Left (ND)
Duration of symptoms, mo 3 12 14 8 24 9 12 12 28 6 4
Diabetes, yes/no No No No No No Yes No Yes No No Yes
Abbreviations: BMI, body mass index; D, dominant; ND, nondominant.

196 | march 2019 | volume 49 | number 3 | journal of orthopaedic & sports physical therapy
 ing their ROM at 6 and 9 months. Shoulder Muscle Strength showed a slight decrease in shoulder flex-
Isolated glenohumeral active abduc- Eight of 11 patients improved their shoul- ion strength. Eight patients increased
tion improved in all patients. Changes der flexion strength at posttreatment. This their shoulder internal rotation strength
were maintained over time in 8 of 11 variable continued improving at 6 months at posttreatment. Changes in this vari-
patients. in 9 of 11 patients. At 9 months, 5 patients able were maintained over time in 9 of 11

Self-reported Pain and Disability Outcomes

TABLE 3
at Baseline, Posttreatment, 6 Months, and 9 Months

VAS, mm DASH (0-100)

Patient B Post 6 mo 9 mo B Post 6 mo 9 mo
1 55.0 26.0 0.0 0.0 69.2 10.0 10.0 10.0
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2 74.0 65.0 38.0 77.0 54.2 72.5 50.0 54.2

3 30.0 22.0 0.0 0.0 27.6 16.7 2.5 0.8
4 45.0 25.0 25.0 0.0 30.8 16.7 40.5 13.3
5 71.5 0.0 26.0 21.0 80.2 40.8 4.2 5.0
6 15.0 38.0 17.0 15.0 21.7 12.9 15.8 15.8
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

7 0.0 0.0 0.0 0.0 45.8 41.7 2.5 2.5

8 40.0 16.0 0.0 0.0 33.3 6.7 0.0 0.8
9 61.0 22.0 10.0 0.0 36.7 14.2 5.0 0.0
10 67.0 25.0 17.0 17.0 48.3 15.0 15.8 16.4
11 57.0 0.0 0.0 0.0 45.0 20.8 0.0 0.0
Mean ± SD 44.8 ± 24.0 21.4 ± 20.0 11.6 ± 14.1 11.3 ± 24.3 44.8 ± 17.8 24.4 ± 19.6 13.3 ± 16.9 10.8 ± 15.8
MD* –23.4 (–71.5-0.0) –33.2 (–57.0-0.0) –33.5 (–61.0-0.0) –20.4 (–59.2-18.3) –31.5 (–76.0-9.7) –34 (–75.2-0.0)
Abbreviations: B, baseline; DASH, Disabilities of the Arm, Shoulder and Hand questionnaire; MD, mean difference; post, postintervention; VAS, visual analog scale.
*Values in parentheses correspond to the maximum and minimum change scores from baseline to posttreatment, baseline to 6 months, and baseline to 9 months.
Journal of Orthopaedic & Sports Physical Therapy®

Range-of-Motion Outcomes at Baseline,

TABLE 4
Posttreatment, 6 Months, and 9 Months

AER, deg AER With OV, deg AABD, deg AABD With OV, deg
Patient B Post 6 mo 9 mo B Post 6 mo 9 mo B Post 6 mo 9 mo B Post 6 mo 9 mo
1 24.0 20.0 44.0 30.0 30.0 28.0 60.0 44.0 70.0 90.0 130.0 144.0 80.0 102.0 146.0 150.0
2 24.0 2.0 32.0 26.0 30.0 2.0 32.2 30.0 35.0 8.0 32.0 16.0 45.0 12.0 48.0 35.0
3 10.0 20.0 12.0 26.0 16.0 28.0 26.0 38.0 80.0 134.0 156.0 160.0 86.0 140.0 164.0 162.0
4 24.0 44.0 40.0 50.0 30.0 50.0 50.0 56.0 86.0 124.0 110.0 140.0 108.0 130.0 136.0 140.0
5 21.0 44.0 20.0 40.0 24.0 48.0 30.0 48.0 50.0 120.0 156.0 144.0 50.0 130.0 164.0 160.0
6 28.0 42.0 40.0 40.0 36.0 48.0 52.0 52.0 88.0 110.0 126.0 112.0 102.0 130.0 140.0 130.0
7 28.0 30.0 40.0 34.0 34.0 40.0 60.0 44.0 144.0 136.0 150.0 136.0 150.0 142.0 152.0 140.0
8 30.0 24.0 46.0 38.0 34.0 46.0 60.0 60.0 108.0 134.0 136.0 144.0 120.0 142.0 140.0 152.0
9 6.0 26.0 38.0 44.0 14.0 34.0 44.0 52.0 66.0 126.0 136.0 140.0 84.0 140.0 150.0 152.0
10 20.0 14.0 22.0 22.0 24.0 14.0 23.0 29.0 36.0 74.0 94.0 96.0 44.0 84.0 110.0 112.0
11 20.0 44.0 42.0 42.0 24.0 50.0 50.0 52.0 88.0 126.0 130.0 135.0 100.0 140.0 148.0 150.0
Mean 21.5 29.6 35.4 37.0 27.2 37.4 46.4 47.6 81.5 110.8 126.2 127.1 92.5 120.8 138.8 137.1
±SD ±7.8 ±14.0 ±1.0 ±7.9 ±7.6 ±15.1 ±13.0 ±8.9 ±30.3 ±38.6 ±36.1 ±40.8 ±31.2 ±40.1 ±33.3 ±37.1
MD 8.1 13.9 15.5 10.2 19.2 20.4 29.3 44.7 45.6 28.3 46.3 44.6
Range* –22-24 –1-32 2-38 –28-24 –1-30 0-38 –27-70 –3-106 –19-94 –33-80 2-114 –10-110
Abbreviations: AABD, active abduction; AER, active external rotation; B, baseline; MD, mean difference; OV, overpressure; post, postintervention.
*Values correspond to the maximum and minimum change scores from baseline to posttreatment, baseline to 6 months, and baseline to 9 months.

journal of orthopaedic & sports physical therapy | volume 49 | number 3 | march 2019 | 197
 [ case report ]
patients. No patients increased shoulder concept of tissue irritability is meant to patients as they were in the current study.
external rotation strength from baseline to reflect the tissue’s ability to handle physi- A differentiating aspect of our study was
posttreatment, 6 months, and 9 months. cal stress, and theoretically relates to the that the progression of treatment at sub-
tissue’s physical status and the degree of sequent visits was dependent on findings
DISCUSSION inflammatory activity present. However, of the reassessment. To our knowledge,
it is important to note that while catego- few studies take reassessment into con-

O
ur study described a clinical- rizing the stage of tissue irritability, as sideration.3,29 Future research should in-
reasoning approach using manual suggested by McClure and Michener35 vestigate not only the interaction of the
therapy and a home stretching and Kelley et al,23 enabled the physical 2 interventions (eg, manual therapy and
program in patients with FSCS. In therapist in this case series to guide in- home stretching program), but also the
this case series, clinically meaningful tensity of treatment, the reliability and single effect of each intervention in each
changes in shoulder pain and disability, validity of this classification system have patient with FSCS.
ROM, or muscle strength were observed not been established. One previous study56 compared the
in 11 patients with primary FSCS. The Impairment-based interventions have effect of high-grade mobilization tech-
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impairment-based approach, aiming previously been used to successfully treat niques with that of low-grade mobiliza-
to specifically address shoulder ROM patients with shoulder pain.1,2,9,15,22,29,51,56 tion techniques in patients with FSCS.
limitations of each patient using a com- The magnitudes of improvements in Unlike this case series, no exercises were
bination of mobilizations (eg, passive ROM, pain, and disability scores ob- performed, and patients were treated
oscillatory mobilizations [Maitland mo- served in this study agree with other stud- more frequently (twice per week versus
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

bilizations] and MWM), was reported to ies investigating the effects of a manual once per week). Significant improve-
be beneficial, while adapting the vigor of therapy approach combined with exer- ments were found in both groups after
the techniques based on perceived tissue cise programs.1,2,22,29 However, the home the first 3 months. The study56 demon-
irritability.41 stretching program used in the current strated similar results to those found in
Perceived tissue irritability was one of study is not comparable to the exercise this case series.
the main factors guiding treatment deci- programs described in the previously Muscle strength has been reported as
sion making in this case series. Recently, published literature, where general non- an outcome measure in 44% of the trials
McClure and Michener35 developed a stretching shoulder exercises were mostly assessing interventions for various shoul-
classification system for guiding rehabili- applied. In addition, interventions (either der disorders, including frozen shoul-
Journal of Orthopaedic & Sports Physical Therapy®

tation intervention of the shoulder, based manual therapy or exercises) were not der.43 Strength testing is not often used
(in part) on 3 levels of irritability. The adapted at and between sessions for their as an outcome measure in studies assess-
ing efficacy of manual therapy techniques
in patients with primary FSCS,42 but was
90
considered in this case series. Bang and
80 Deyle2 also observed a greater improve-
ment in strength over a longer term in a
70
group of patients with subacromial im-
60 pingement syndrome receiving manual
DASH (0-100)

therapy compared to another group re-

50
ceiving exercise only.
40 Improvements were observed in all
measured glenohumeral ROM direc-
30
tions. This finding was expected, as
20 most of the mobilizations included in
the manual therapy program specifically
10 addressed soft tissue restrictions within
0
the glenohumeral joint. Only 1 scapular
Baseline Posttreatment 6 mo 9 mo mobilization (eg, scapular tilt) was used
when the patient presented with a limita-
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6
Patient 7 Patient 8 Patient 9 Patient 10 Patient 11 tion in external rotation at 0° of abduc-
tion.9 When used within a multimodal
FIGURE 2. Scores on the DASH over time for each patient. Abbreviation: DASH, Disabilities of the Arm, Shoulder manual therapy approach, scapular mo-
and Hand questionnaire.
bilizations can be useful for treating a

198 | march 2019 | volume 49 | number 3 | journal of orthopaedic & sports physical therapy
 specific subgroup of patients with FSCS gressive reduction of stiffness and im- https://doi.org/10.1016/j.jse.2014.01.006
who fit different criteria from a shoulder provement in ROM are expected. 5. Delitto A. Pragmatic clinical trials: implementa-
kinematics prediction model.61,63 Further This case series has limitations. First, tion opportunity, or just another fad? Phys
Ther. 2016;96:137-138. https://doi.org/10.2522/
research might investigate useful clinical the lack of a control group precludes con-
ptj.2016.96.2.137
criteria to identify expected responders to clusions regarding the outcomes being a 6. Dimond D, Donatelli R, Morimatsu K. The Bare
different types of shoulder mobilizations result of interventions. The improve- Minimum: Donatelli Shoulder Method Assessment
in patients with FSCS. ments observed in this study may only and Treatment. 2nd ed. Self-published; 2011.
7. Donatelli R, Greenfield B. Case study: reha-
Improvements in pain, function, and reflect the natural course of the disease.
bilitation of a stiff and painful shoulder: a
ROM in 3 patients who presented with Additionally, included patients presented biomechanical approach. J Orthop Sports Phys
type 2 diabetes mellitus (patients 6, 8, and with different baseline levels of shoulder Ther. 1987;9:118-126. https://doi.org/10.2519/
11) were similar to the remaining cases. pain and disability, which may have influ- jospt.1987.9.3.118
8. Donatelli R, Ruivo RM, Thurner M, Ibrahim MI.
Type 2 diabetes is considered a risk factor enced their responsiveness to treatment.
New concepts in restoring shoulder elevation in
for FSCS.58 Shoulder pain and disability a stiff and painful shoulder patient. Phys Ther
are very common in patients with type 2 CONCLUSION
Downloaded from www.jospt.org at on March 14, 2025. For personal use only. No other uses without permission.

Sport. 2014;15:3-14. https://doi.org/10.1016/j.

diabetes, and they have shown substantial ptsp.2013.11.001

A
9. Doner G, Guven Z, Atalay A, Celiker R. Evalution
reductions in shoulder ROM, in particu- multimodal manual therapy ap-
of Mulligan’s technique for adhesive capsulitis
lar decreased external rotation, and muscle proach, together with a home of the shoulder. J Rehabil Med. 2013;45:87-91.
strength compared to controls.46,47 To our stretching program, based on tissue https://doi.org/10.2340/16501977-1064
knowledge, studies assessing the efficacy of irritability and specific impairments in 10. Dundar U, Toktas H, Cakir T, Evcik D, Kavuncu V.
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Continuous passive motion provides good pain

manual therapy interventions in patients shoulder mobility (eg, internal/external
control in patients with adhesive capsulitis. Int
with FSCS and with or without diabetes passive ROM at different levels of abduc- J Rehabil Res. 2009;32:193-198. https://doi.
mellitus are scarce, but show comparable tion) resulted in reduced shoulder pain org/10.1097/MRR.0b013e3283103aac
results.11 and improved ROM and muscle strength 11. Düzgün I, Baltaci G, Atay ÖA. Manual therapy
is an effective treatment for frozen shoulder in
In the present study, treatment was in patients with primary FSCS. Future
diabetics: an observational study. Eklem Hastalik
initiated at an average of 1 year after onset clinical studies are needed to evaluate the Cerrahisi. 2012;23:94-99.
of symptoms, and patients were followed effect of this tailored manual therapy and 12. Gaspar PD, Willis FB. Adhesive capsulitis and dy-
for 6 months after treatment. Different stretching exercise program, considering namic splinting: a controlled, cohort study. BMC
Musculoskelet Disord. 2009;10:111. https://doi.
authors have elaborated on the natural tissue irritability and comparing this to
Journal of Orthopaedic & Sports Physical Therapy®

org/10.1186/1471-2474-10-111
history of FSCS and reported variable the natural course of the condition in a 13. Green S, Buchbinder R, Forbes A, Bellamy N.
average durations of the disease, ranging larger population with FSCS. t A standardized protocol for measurement of
from 15 months54 to several years.60 In ad- range of movement of the shoulder using the
Plurimeter-V inclinometer and assessment of its
dition, 3 (eg, painful, stiff, recovery)44 or
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of frozen shoulder: fact or fiction? A systematic doi.org/10.2522/ptj.20060295
review. Physiotherapy. 2017;103:40-47. https:// 63. Y ang JL, Jan MH, Chang CW, Lin JJ. Effective-
doi.org/10.1016/j.physio.2016.05.009 ness of the end-range mobilization and scapular WWW.JOSPT.ORG
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 [ case report ]
APPENDIX A

MANUAL THERAPY TECHNIQUES*

Technique Description Illustration
General capsule-stretching technique
Lateral humerus distraction58 The patient is in supine, with the involved extremity close to the edge of
the table and the shoulder flexed to 90°. The therapist’s hands sta-
bilize the elbow and lateral border of the scapula. The therapist uses
body weight to provide a lateral humerus distraction through a belt
This technique is applied in all patients at the beginning of the treat-
ment
Perform 5 repetitions as a sustained mobilization, holding each repeti-
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tion 1 minute

Limitation: ER at 0° of humeral abduction

Scapular tilt and distraction7 (ONLINE VIDEO) The patient is in sidelying, with the upper extremity relaxed at the side.
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

The therapist’s caudal hand holds the inferior angle of the scapula
and the cephalad hand grasps its vertebral border. The therapist’s
sternum is the third contact point to assist the tilt. A distraction force
to the scapula away from the thoracic wall is performed to patient
tolerance. Perform 5-second holds, alternating with 5-second rests,
during 5 minutes
After 2 weeks, progress to 10-second holds, alternating with 10-second
rests
Journal of Orthopaedic & Sports Physical Therapy®

Subscapularis soft tissue techniques54 With the patient in supine, the following techniques are applied
• Moderate sustained pressure for 3 sets of 90-second cycles applied
over myofascial trigger point(s). Pressure level is modified from
moderate to deep, according to patient’s tolerance
• Soft tissue mobilizations parallel and perpendicular to muscular
fiber orientation. Perform during 1 minute
• Continuous pressure over myofascial trigger points while the thera-
pist holds and assists the shoulder in flexion and abduction until end
range. Perform 5 sets of 30 movements

Oscillatory anterior/posterior mobilization58 The patient is in supine, with the arm placed at 0° of humeral abduc-
tion. The therapist’s hand on the anterior part of the shoulder applies
an anterior/posterior oscillatory force over the humeral head, with
the scapula stabilized. The patient concurrently holds the shoulder
in end-range ER with the mobilization technique
Perform 5 sets of 1-minute duration

Table continues on page D2.

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 [ case report ]
APPENDIX A

Technique Description Illustration

Anterior/posterior mobilization with movement33 The patient is in supine, with the arm placed at 0° of humeral abduc-
(ONLINE VIDEO) tion. The therapist’s hand on the anterior part of the shoulder applies
an anterior/posterior sustained force over the humeral head, with
the scapula stabilized. The patient concurrently performs active
ER to the end of the pain-free range (ie, 0/10 on an NPRS) with the
mobilization technique
Perform 3 sets of 10 repetitions
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Coracohumeral ligament mobilization7 The patient is in sidelying. The therapist’s caudal hand grasps the pa-
(ONLINE VIDEO) tient’s arm above the elbow while the patient’s forearm rests on the
therapist’s arm. The cephalad hand grasps the vertebral border of
the scapula and tilts it away from the thoracic wall. The caudal hand
takes the patient’s arm into end-range ER and applies an inferior
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

glide through the long axis of the humerus. Once the barrier is felt,
the therapist tilts the scapula. Then, the humerus can be externally
rotated further and the scapular tilt can be repeated
Perform 3 sets of 10 repetitions

Superior/inferior glide mobilization25 The patient is in supine, with the arm at the side. The therapist’s caudal
hand holds the patient’s wrist. The cephalad hand grasps the
patient’s arm above the elbow crease and applies an inferior glide
while the patient’s arm is positioned into end-range ER
Perform 5 repetitions as a sustained mobilization, holding each repeti-
Journal of Orthopaedic & Sports Physical Therapy®

tion 1 minute

Rotator cuff interval stretch25 The patient is in sidelying, with the arm at the side. The therapist’s
caudal hand fixes the patient’s hand. The cephalad hand moves the
patient’s elbow toward the table
Perform 5 repetitions as a sustained mobilization, holding each repeti-
tion 1 minute

Table continues on page D3.

d2 | march 2019 | volume 49 | number 3 | journal of orthopaedic & sports physical therapy
 APPENDIX A

Technique Description Illustration

Limitation: ER at 45° of humeral abduction
Oscillatory anterior/posterior mobilization58 The patient is in supine, with the arm placed at 45° of humeral abduc-
tion. The therapist’s hand on the anterior part of the shoulder applies
an anterior/posterior oscillatory force over the humeral head, with
the scapula stabilized. The patient concurrently holds the shoulder
in end-range ER with the mobilization technique
Perform 5 sets of 1-minute duration
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Anterior/posterior mobilization with movement33 The patient is in supine, with the arm placed at 45° of humeral abduc-
tion. The therapist’s hand on the anterior part of the shoulder applies
an anterior/posterior sustained force over the humeral head, with
the scapula stabilized. The patient concurrently performs active
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ER to the end of the pain-free range (ie, 0/10 on an NPRS) with the
mobilization technique
Perform 3 sets of 10 repetitions

Middle glenohumeral mobilization7 The patient is in supine, with the involved extremity close to the edge of
the table. The patient’s arm is placed at 45° of humeral abduction.
The therapist’s caudal hand on the posterior glenohumeral joint
glides the head of the humerus anteriorly. The cephalad hand
Journal of Orthopaedic & Sports Physical Therapy®

stabilizes the scapula

Perform 5 repetitions as a sustained mobilization, holding each repeti-
tion 1 minute

Limitation: ER at 90° of humeral abduction

Posterior/anterior humeral head mobilization23 The patient is in prone, with the arm placed at 90° of humeral abduc-
tion, the elbow flexed, the glenohumeral joint off the table, and a ful-
crum over the coracoid process. The therapist’s lateral hand grasps
the patient’s arm above the elbow crease and takes the patient’s
arm into end-range ER. Simultaneously, the cephalad hand on the
posterior part of the humerus applies a posterior/anterior force over
the humeral head, with the scapula stabilized
Perform 5 repetitions as a sustained mobilization, holding each repeti-
tion 1 minute

Table continues on page D4.

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 [ case report ]
APPENDIX A

Technique Description Illustration

Superior/inferior glenohumeral glide7 The patient is in supine, with the involved extremity close to the edge
(ONLINE VIDEO) of the table. The patient’s arm is in 90° of humeral abduction. The
cephalad hand on the superior glenohumeral joint, inferior to the
acromion, applies a superior/inferior force over the humeral head.
The therapist concurrently holds the shoulder in end-range ER with
the mobilization technique
Perform 5 repetitions as a sustained mobilization, holding each repeti-
tion 1 minute
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Superior/inferior mobilization with movement22 The patient is in supine, with the arm placed at 90° of humeral abduc-
tion. The therapist’s cephalad hand performs a sustained superior/
inferior passive shoulder mobilization while the caudal hand
stabilizes the humerus. The patient concurrently performs active
ER to the end of the pain-free range (ie, 0/10 on an NPRS) with the
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

mobilization technique
Perform 3 sets of 10 repetitions

Limitation: IR at 30° of humeral abduction

Anterior/posterior mobilization58 The patient is in supine, with the arm placed at 30° of humeral abduc-
tion. The therapist’s hand on the anterior part of the shoulder applies
an anterior/posterior force over the humeral head, with the scapula
stabilized. While sustaining the anterior/posterior force, the therapist
Journal of Orthopaedic & Sports Physical Therapy®

moves the shoulder to end-range IR

Perform 5 repetitions as a sustained mobilization, holding each repeti-
tion 1 minute

Limitation: IR at 60° of humeral abduction

Anterior/posterior mobilization58 The patient is in supine, with the arm placed at 60° of humeral abduc-
tion. The therapist’s hand on the anterior part of the shoulder applies
an anterior/posterior force over the humeral head, with the scapula
stabilized. While sustaining the anterior/posterior force, the therapist
moves the shoulder to end-range IR
Perform 5 repetitions as a sustained mobilization, holding each repeti-
tion 1 minute

Table continues on page D5.

d4 | march 2019 | volume 49 | number 3 | journal of orthopaedic & sports physical therapy
 APPENDIX A

Technique Description Illustration

Limitation: IR at 90° of humeral abduction
Anterior/posterior mobilization58 The patient is in supine, with the arm placed at 90° of humeral abduc-
(ONLINE VIDEO) tion. The therapist’s hand on the anterior part of the shoulder applies
an anterior/posterior force over the humeral head, with the scapula
stabilized. While sustaining the anterior/posterior force, the therapist
moves the shoulder to end-range IR
Perform 5 repetitions as a sustained mobilization, holding each repeti-
tion 1 minute
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Limitation: IR at 30° of humeral abduction and

extension
Prone IR hang7 The patient is in prone, with the dorsum of the hand on the lumbar
spine (if the patient is unable to internally rotate enough, place
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the hand on the table). The therapist’s cephalad hand stabilizes

the scapula along the spinal border. The caudal hand applies a
downward force on the patient’s medial elbow
Perform 5 repetitions as a sustained mobilization, holding each repeti-
tion 1 minute

Limitation: IR with hand behind back

Journal of Orthopaedic & Sports Physical Therapy®

Superior/inferior glenohumeral glide: hand The patient is in sidelying, with the hand placed at the end-range posi-
behind back33 (ONLINE VIDEO) tion of “hand behind back.” The therapist’s cephalad hand stabilizes
the scapula. The caudal hand holds the forearm and applies a
superior/inferior force. The technique may be enhanced by using a
mobilization belt
Perform 5 repetitions as a sustained mobilization, holding each repeti-
tion 1 minute

Hand-behind-back mobilization with movement22 The patient is in sitting, with the hand behind the back at the end-range
position. One hand is placed on the forearm just distal to the elbow
crease. The other hand is placed dorsally to stabilize the scapula.
The therapist provides a sustained caudal glide along the line of the
humerus
The patient concurrently moves the arm behind the back, assisted
by the therapist’s abdomen, to the end of the pain-free range (ie,
0/10 on an NPRS) with the mobilization technique. Overpressure is
applied by the patient’s hand, assisting the affected shoulder further
into the pain-free range
Perform 3 sets of 10 repetitions
Table continues on page D6.

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 [ case report ]
APPENDIX A

Technique Description Illustration

Limitation: shoulder flexion
Posterolateral mobilization with movement22 The patient is seated and the therapist stands beside the patient on the
opposite side of the affected shoulder. One hand is placed posteri-
orly over the scapula, while the thenar eminence of the other hand
is placed over the anterior aspect of the humeral head. A sustained
posterolateral gliding force is applied to the humeral head along the
plane of the glenohumeral joint. The patient is then asked to raise
the affected arm in the scapular plane to the end of the pain-free
range (ie, 0/10 on an NPRS) simultaneously with the mobilization
technique
Perform 3 sets of 10 repetitions
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Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Abbreviations: ER, external rotation; IR, internal rotation; NPRS, numeric pain-rating scale.
*Each technique is adapted, in intensity and duration, to the patient’s irritability level.
Journal of Orthopaedic & Sports Physical Therapy®

d6 | march 2019 | volume 49 | number 3 | journal of orthopaedic & sports physical therapy
 APPENDIX B

HOME STRETCHING TECHNIQUES*

Exercise Objectives Soft Tissue Targeted Description Illustration
Stretch into ER at 0° of abduction9 Subscapularis muscle The patient is in supine, with the shoulder sup-
ported on a foam wedge in 0° of abduction in
the scapular plane, allowing gravity to produce
the intended stretch into glenohumeral ER
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Stretch into ER at 45° of abduction9 Subscapularis muscle and middle The patient is in supine, with the shoulder sup-
(ONLINE VIDEO) glenohumeral ligament ported on a foam wedge in 45° of abduction in
the scapular plane, allowing gravity to produce
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the intended stretch into glenohumeral ER

Stretch into ER at 90° of abduction9 Inferior glenohumeral ligament The patient is in prone, with the shoulder at 90°
complex of abduction and the forearm resting on a
Journal of Orthopaedic & Sports Physical Therapy®

foam wedge, maintaining the intended stretch

into glenohumeral ER

Stretch into IR at 30° of abduction9 Superior portion of the posterior The patient is in sidelying, with the shoulder
capsule supported on a foam wedge in 30° of
abduction in the scapular plane, allowing
gravity to produce the intended stretch into
glenohumeral IR

Table continues on page D8.

journal of orthopaedic & sports physical therapy | volume 49 | number 3 | march 2019 | d7
 [ case report ]
APPENDIX B

Exercise Objectives Soft Tissue Targeted Description Illustration

Stretch into IR at 60° of abduction9 Superior portion of the posterior The patient is in sidelying, with the shoulder
capsule supported on a foam wedge in 60° of
abduction in the scapular plane, allowing
gravity to produce the intended stretch into
glenohumeral IR
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Stretch into IR at 90° of abduction9 Posterior capsule The patient is in sidelying, with the shoulder
supported on a foam wedge in 90° of
abduction in the scapular plane, allowing
gravity to produce the intended stretch into
glenohumeral IR
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Abbreviations: ER, external rotation; IR, internal rotation.

*Patients performed the corresponding stretching exercises according to their glenohumeral limitations. Each stretching exercise was adapted, in intensity
and duration, to the patient’s irritability level. Each exercise lasted for 10 minutes. A 1.5-kg weight was used. In patients with high irritability, the stretching
exercises need to be performed at low intensity, with a short duration (1-5 seconds) and no pain (ie, 0/10 on a numeric pain-rating scale).
Journal of Orthopaedic & Sports Physical Therapy®

d8 | march 2019 | volume 49 | number 3 | journal of orthopaedic & sports physical therapy
 APPENDIX C

PROGRESSION OF TECHNIQUES
Improvement of ER at 0° of abduction.

Typical progression of the oscillatory AP mobilization technique used in this case series

Improvement of Increase grade of

ROM and/or mobilization
irritability Progress in starting
position (ie, AP
glide in ER at
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45° of abduction
High irritability AP glide
Grades I-II

No change in Continue with the

Physical exam: Oscillatory AP ROM and/or same
decreased ER mobilization Moderate AP glide Next session: irritability mobilization
at 0° of 5 times 1 irritability Grades I-IV reassessment parameters and
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

abduction minute reassess in the

next sessions

Low irritability AP glide

Grades III-IV Worsening of Decrease glide of
ROM and/or mobilization (if
irritability possible)
Journal of Orthopaedic & Sports Physical Therapy®

Typical progression of the stretch into ER at 0° of abduction used in this case series

Improvement of Progress in starting

ROM and/or position (ie, at
High irritability Short duration, irritability 45° of abduction
pain free (5
times 1-5
seconds)
No change in Continue with the
Physical exam: Stretch into ER Moderate Short duration (5 ROM and/or same stretch
decreased ER at 0° of irritability times 5-15 Next session: irritability and reassess in
at 0° of abduction seconds) reassessment the next
abduction
sessions

Low irritability Increased

duration with Worsening of Adapt the stretch
the joint near ROM and/or duration and
the end range irritability position until
reported as
“pain free”

Abbreviations: AP, anteroposterior; ER, external rotation; ROM, range of motion.

journal of orthopaedic & sports physical therapy | volume 49 | number 3 | march 2019 | d9