Shoulder Impingment: Improving External Rotation (Full Version)

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VagusX -> Shoulder Impingment: Improving External Rotation (February 27, 2008 12:13:20 AM)

I run into tons of degenerative RTC tears and shoulder impingement cases.  Many of these cases involve significant reduction in GH ER with pain at the endrange. 

Approaches that I have had success with is Total End Range Time (TERT) stretches (10+ minute prolonged strech,) but for a good many, TERT stretches are too uncomfortable and untolerable.  I can get short term improvements with rhythmic mobilisations Grade III-IV, but usually not much carryover.   I hit plateaus too frequently on this type of patient in regards to ROM.

I do spend a good amount of time working RTC/Scapular mm in pain free (minimal pain) at the same time. 

What are others doing to regain this motion?  

On a side note, does anybody work patients through painful motions (teeth gritting pain) either while rangeing or strengthening?



KAK -> RE: Shoulder Impingment: Improving External Rotation (February 27, 2008 7:08:44 AM)

I simply have them work on ER supine with a cane.  I make sure the shoulder is in neutral or slight flexion in the saggital plane, find the most comfortable amount of abduction (usually scapular plane) and have them work 2-3 times per day 10-20 reps with a 5-10 second hold.  As range and tolerance improve I increase the amount of abduction.
 
In the clinic I do a lot of mobs.  I most always find posterior and inferior capsule tightness in these patients.  I often do inferior mobs in while positioned in various degrees of ER/ABD.  Also, sometimes combining a posterior mob with the movement of ER is much less painful and effective for some patients (sustained posterior glide while doing passive ER).  I also range what ever planes of movement are restricted (avoiding horizontal adduction).
 
I find the subscapularis tendon is often quite irritable and I will use ionto on it or which ever tendon is the hottest.
 
I never do painful strengthening exercises.  I will not go into pain gritting ranges with ROM either, because if they are gritting their teeth, they are guarding, and it does no one any good to try to push through guarding (as if we could)…
 
 



eam -> RE: Shoulder Impingment: Improving External Rotation (February 27, 2008 9:32:15 AM)

I am finding that the joint mobs generally do not work for persistent ER limitations except for the one where you apply a posterior glide and have the pt move into ER.  More and more I feel that low load long duration stretching works alot better than pushing these poor people into horrible pain.  If they are breathing heavily, biting their teeth what help is it?  Their poor nervous system is freaking out and the carryover is poor.  There was another thread here that discussed this recently but I don't remember where it was.  It was recent though.
Erica 



VagusX -> RE: Shoulder Impingment: Improving External Rotation (February 27, 2008 2:45:50 PM)

Thanks for the responses. 

What are you guys doing about the pain?  Some of these patient are coming in with 10 degrees of ER in the scapular plane.  You put them on a super low load TERT strech and before a minute or two is up they're in agony.  At this point I say to myself if I take any more load off this stretch I won't be doing anything.

The same thing goes with prolonged static posterior/inferior joint mobs.  I may do an 8 minute hold, but either during or after the mob some are complaining of pain. 

What grade are people mobilising to get the desired effects?  Are you holding posterior III's and IV's while making them move into ER?



Shill -> RE: Shoulder Impingment: Improving External Rotation (February 27, 2008 4:52:59 PM)

I can say that I am willing to put the patient through the teeth gritting end range pain if the results are favorable, and if, 5 minutes after the stretch, they are no worse, nor are they worse the remainder of the day.  It often depends on the patient.  I agree with KAK on strengthening being relatively pain free, but stretching is different.  One can argue that this is not helpful, but it also may not be harmful.  Again, if the results show the ROM gains are maintained from visit to visit, AND, they are truly experiencing hurt, not harm, I am fine with this.  I also truly believe that patients will not let you harm them, provided they are advised to notify you when they reach the limit of what they are willing to put up with.  I recently ordered a dynamic splint for someone who started with 30 degres of ER (or less, I dont recall).  I can post how this worked when enough time has gone by to do so.



TexasOrtho -> RE: Shoulder Impingment: Improving External Rotation (February 27, 2008 8:23:41 PM)

I agree with much of what has been said.  I will try hard not to force ROM in any plane unless it can be achieved without pain or with minimal pain(which is pretty rare).  My approach has changed quite a bit in this regard.  I will have the patient perform supine resting position ER with a wand for a few visits.  I hate watching them only get 10-20 degrees, but I allow it while we get their pain under control with whatever technique or modality works best for them.

I see significant improvements in motion simply by building trust and reducing pain.  Once this is improved to the point that they can tolerate end-range grade II mobs in the resting postion, I will begin progressively mobilizing. 

First ER mobs in resting position, then closer to end range scapular abduction, end-range frontal plane abduction, end-range sagittal plane flexion.  I rarely do a ton of long lever stretching until pain levels are at an absolute minimum.

Long duration stretches (IMHO) tend to be more painful due to the ischemic "wringing out effect" of placing a tissue under extreme tension for 20-30 seconds.  I will not perform this unless I have tried multiple combinations of just about everything else. 

My 2 yen. 



KAK -> RE: Shoulder Impingment: Improving External Rotation (February 27, 2008 8:58:46 PM)

ValgusX,
 
I take different approaches to patients depending if they are pain or stiffness dominant.  I will approach a stiffness dominate patient much more aggressively. I find that with the pain dominate patient, it’s best to let him/her have control of the load and duration of stretch initially anyways. From my experience a stretch held for longer than 10 seconds is too much for a pain dominate patient.  When I am doing the stretching with these patients, I tend to go into the stretch very slowly and at the first hint of muscle guarding back off.  With patience they usually relax and let you take it a bit further as you work and their trust grows.  Also, if the subscapularis is involved, you may find more range and less pain closer to 90 degrees abduction where it’s the ligament rather than the subscapularis getting the stretch. 
 
As regards to what grade mob I use it depends on what is effective.  Also, when I do ER with a sustained AP glide I don’t make them go into ER- I gently assist until I feel muscle guarding.  I only do 10 reps or so at a time.  I can’t imagine doing a sustained mob for 8 minutes. These “degenerative tears and impingement” patients generally have a lot of inflammation.  You may be being too aggressive, furthering the inflammation and slowing progress.
 
I have on a rare occasion referred patients to an ortho in hopes of cortisone shot which can go a long way in helping the whole inflammatory/pain issue.
 



eam -> RE: Shoulder Impingment: Improving External Rotation (February 28, 2008 9:28:43 AM)

I had a patient in yesterday s/p proximal humeral fracture with hardware placement and then removal.  2 mos of sub acute and then home care.  ROM flexion 40 degrees abd 45 degrees  ER O IR to chest wall.  With all that scarring and fibrotic tissue in this poor woman's shoulder I don't think I am going to get anywhere doing jt mobs for 3 x 30.  Although she was in obvious pain I did some ROM with some low load stretching into tolerable pain, after a while she relaxed and felt better, feeling some release from stretch pain only.  I think it depends on the patient presentation. I also gave her some basic movement exercises , so she can be in control and her brain can accomodate to this new movement.   This woman had surgery in 10/07, so I think I have my work cut out for me.[;)]



RSBMPT -> RE: Shoulder Impingment: Improving External Rotation (March 5, 2008 7:44:42 PM)

Is it limited at endrange in all positions? Neutral vs 45* of abd vs 90* of abd.  I am w/ Shill on this one, as long as the pain does not persist following the stretch than a few seconds following its application.  Scapular position, and scapular stabilization strength are also very important.  doing your best to ensure that the force couples are working as optimally as can be achieved.  Alternately, though not comfortable you can try a subscap release as well as MET to the subscap should it be indicated.



eam -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 10:09:55 AM)

Since my patient barely got to 45 of abduction, I just tested it at neutral. 
Erica



cottonra -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 10:19:05 AM)

According to the EVIDENCE (Vermeulen 2000, 2006, Yang 2007, Johnson 2007) End Range joint mobilization within the constraints of pain and avoiding any accessory muscle firing (such as one may get with "teeth-gritting pain") is most effective in gaining ROM with these patients. 

I see these patients on a daily basis who were tortured during previous treatment sessions, who show up to our clinic and get good outcomes (ASES outcomes database with 450+ shoulder patients, not just anecdotal evidence) with the evidence-based approach.  To the original poster, aggressive (Grade 3-4) end ROM joint mobs and stretching (static and contract-relax) all done within the constriants of pain....ie: no teeth gritting is evidence based treatment for these patients. 

So, according to the evidence, should we ever be stretching our patients shoulders to this level of pain?  Maybe you think your pts are better and improved when they don't return, when they actually refuse to come back to you for continued teeth-gritting.  What would those of you who do this type of stretching suggest we are doing to the tissues with this type of stretch other than increasing local inflammatory response?  Where in our education did we learn that inflicting this pain during a tx session is OK?

Ryan Cotton, PT, DHS, OCS 



Shill -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 11:34:47 AM)

Ryan,

As you so adeptly stated regarding accessory muscle firing, "such as one may get with "teeth-gritting" .  The key word here is MAY.  Any PT should be able to recognize this, and adjust forces appropriately.  However, even with this, there will be temporary pain from taking an adaptively shortened tissue to its premature end range.  This is the definition of mechanical pain. Non-damaging, mechanical pain.  You use the word torture as well.  Education on the what and why of what they are feeling allows them to understand that not all pain is bad.   
Can you tell me that you have indeed seen 450+ adhesive capsulitis patients, so that others will know that you are not including other shoulder diagnoses in your outcome statement?  If these outcomes are just on shoulder patients, you are comparing apples to eggplants.  If you have seen this many specific patients with adhesive capsulitis, then you must be about 109 years old!
The latest Vermeulen study you cited commented: "HGMT proved to be more effective than LGMT", and they discussed that any pain persisting more than 4 hours required adjustment for the next session.  They also commented that the LGMT (pain free group) may have simply shown their changes, (which admittedly were still reported as statistically significant) due to the natural course of the condition, as there was no control group.



jlharris -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 12:04:06 PM)

Like your post Ryan.  Thanks for contributing.

Side note: What does "DHS" signify in you credentials?  Thanks.



cottonra -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 12:27:25 PM)

Shill,
I'm not going to argue or take cheap shots, how about a civil professional discussion?

You stated in a previous post that you would put your patient thru "teeth gritting pain if the results are favorable."  I would have a heck of a time believing that these pts were not getting accessory firing (guarding) during their teeth gritting pain.  

In his research Vermuelen reported that aggressive mob accompanied by discomfort and no accessoery muscle firing was most effective for increasing ROM, but strict adherence was paid to not causing pain and guarding (I can only assume teeth-gritting pain would fall into the latter category.)

Concerning this painful type of stretching, the EVIDENCE states the contrary, I'm just sharing the evidence.  Show me evidence for that aggressive stretching/mob improves these pts outcomes.  I have read nothing reporting the positive effects of stretching into a painful ROM.  When teaching Cont Ed on the shoulder, this discussion always occurs.  I think there is a real problem in our profession of PTs being far to aggressive with these pts and putting them in a lot of unneeded pain during treatment.

Of course I don't have a database of 450 ad cap patients, and never claimed to.  Of the 450, however, 70 are ad cap, so I feel I have a fair idea of their management by this point.    

Ryan Cotton, PT, DHS, OCS   



cottonra -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 12:30:18 PM)

Glad you agree Jason. 

In the aphabet soup that is PT, DHS is Doctor of Health Science (a terminal post-professional degree from U of Indianapolis)

Ryan Cotton, PT, DHS, OCS



proud -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 1:06:56 PM)

Ryan,

I think we all have to be careful with blanket statements. When it comes to the shoulder, the treatment truly does depend upon the diagnosis. For example, in the case of rotator cuff tendinosis( rather than 'itis'), there is evidence that loading the tendons is required( some authors feel pain is required within the loading protocols). I tend to agree. Histologically there is an apparent increase in tenocytes and classic inflammation cells are typically absent. In fact, the goal of rehab is collagen turnover and remodelling. Gentle mobilization will accomplish nothing there. In the case of "itis" we will want to create more subacromial space vis mobs, muscle imbalance work, postural work etc. Not so for "osis" and painfree Physio will typically fail.

In chronic rotator cuff conditions, this loading component is often missing in many PT protocols. For this sub group, I think pain may actually be required to promote the required remodelling. In fact, loading MUST be sufficient to PRODUCE a degree of pain that settles once the loading has been ceased. This management strategy for the dysfunctional contractile unit is in line with contemorary knowledge about tendon pathology. So from that, I tend to agree more with Shill here folks.

Some good work on this from Khan et al, Kraushaar et al to name a couple.

Regards.



cottonra -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 1:58:35 PM)

Proud,
I am in complete agreement concerning your statements of loading contractile tissues in those pts with an "itis", vs an "osis."  Some pain is appropriate with loading (strengthening) in the pt with an "osis" to promote healing at the tissue level.  Khan and Krashaar support this tissue healing/loading model.

But what is being discussed here is a ROM capsular restriction.

Ryan Cotton, PT, DHS, OCS




Shill -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 2:05:26 PM)

Proud,
you always seem to say what I wanted to say far better than I say it.  Thanks for providing the eloquence that is definitely escaping me today.

Ryan, Arguing and taking cheap shots is not something I enjoy on this forum either.  However, you jumped on the idea that someone who allows patients to hurt a little during treatment is a torturer who gets poor outcomes.  I dont want to argue with you either, but it was you who said this, I am pointing this out for an exercise in gentle reflection.  Your inclusion of outcomes numbers was misleading, whether intentional or not, so thanks for correcting this. 
The strength of evidence for adhesive capsulitis treatment is really not too strong, and is quite frankly disappointing.  I will be the first to admit that I am doing nothing to further this, as I am not a researcher.  Yes there is evidence, but is it really that good, and were the studies well done, well controlled, etc?  Mostly, not so much.  So, that said, Im not putting all of my eggs in one basket just yet.   I do agree that end range mobilization shows good promise, and I do utilize this regularly.  I actually wish that interscalene blocks would be done on patients prior to their PT visits!  However, what I have seen regarding stretching to the point of teeth gritting, but not beyond shows promise as well.



proud -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 2:45:33 PM)

Ryan,

Two things:

1. The very first sentence on this thread was:

quote:

I run into tons of degenerative RTC tears and shoulder impingement cases.  Many of these cases involve significant reduction in GH ER with pain at the endrange.


I don't see that as a call for advice on capsular restrictions? And besides, 'capsular restriction' is not a diagnosis but rather a finding. Often a noncontributory one at that.

2. If you are talking capsular restrictions, in order for me to support your comments we would have to be talking about specifically Adhesive capsulitis. Is this what you are limiting your input to? Perhaps that is the confusion here. I did not see the initial query as an adhesive capsulitis case at all.

In any case, just to add to your comments on painfree mobs for adhesive capsulitis...Diercks et al J. Shoulder elbow surg 2004 supports your thoughts on avoiding aggressive mobilizations for adhesive capsulitis. I would also recommend painfree mobs specifically in the inflammatory stage... along with a cortizone injection...



cottonra -> RE: Shoulder Impingment: Improving External Rotation (March 6, 2008 3:40:01 PM)

Proud,
When you and I are on the same page, we certainly seem to agree.  I AM speaking of capsular restrictions which are limiting ROM, but not limiting that to adhesive capsulitis.  Someone can have a stiff and painful shoulder (ie.  capsular restriction) without having adhesive capsulitis.  The original post was concerning RCT with ROM limitations (I assumed they were speaking of capsular limitations).  On a side note, though, would those pts with a  painful RCT be a candidate for painfully aggressive stretching either?

Steve,
Lets continue on our exercise of gentle reflection.  You originally said that teeth gritting pain during stretching was OK if the outcome was positive...now you're backtracking to "hurting a little during treatment"  Certainly a semantics point, but what does a student at a clinic perceive when an attending PT states teeth gritting pain is OK. 

It is easy to cast stones at research from the sidelines (ie..its not good, not well controlled, etc) I would beg to differ about this research.  These studies area good example of clinical research effecting outcomes, certainly not up to lab standards, but it represents what you and I do all day in the clinic.  This research is what is out there defining our current practice patterns.  I have not yet seen your sources of evidence for aggressive painful stretching and imrpoving ROM and function in shoulder pts.   

I ask this of all:
1.  If your mother presented to a clinic with capsular ROM restrictions in her shoulder, considering the current evidence, what would you hope her treatment plan to look like?
2.  Even if there was evidence that painful stretching was as effective as non-painful stretching, why would you choose the painful option?

Ryan Cotton, PT, DHS, OCS



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