These stretches are held for at least one minute per repetition and are performed two or more times daily. As the patient progresses to pain-free and improved mobility, internal rotation stretches and posterior glide joint mobilizations are added to the program. This progression requires an important clinical adjustment. At this point, it is advisable to alternate clinical days between treatment of the anterior capsule and posterior capsule. This rotation of mo - bilizations and stretches protects against common pain flare-ups and allows for overall improved capsular mobility. Figure 4: External Rotation
inferior glides at 90° of abduction with the addition of external ro- tation. Phase 5 shows distraction of the joint in the direction of the inferior glides. Phase 6 references the bidirectional linear forces used to mobilize the acromioclavicular joint. The acromioclavicu- lar joint is usually restricted in the settled stage of any prolonged shoulder stiffness case. When Phase 4 is achieved, several key milestones are present: 5. Patients likely have restored daily functional movement, with minimal daily pain periods. 6. This position correlates to active ROM for elevation from 120- 140° and external rotation of 45‑50° at 90 ° of abduction. 7. It signals the readiness of the patient to tolerate isolated pos- terior glides and more aggressive static stretches for internal rotation. 8. Active ROM at this level is a sign that further invasive treat- ments, such as MUA and surgery, are not indicated. 9. This position is also the highest level of elevation that allows for safe joint mobilization due to the close apposition to bony elements. Figure 3
Figure 5: Internal Rotation
Evidence-based practice: Early applications of stretch - ing and joint mobilization in the frozen phase should concentrate on improving elevation mobility first, which is produced with inferior glides. Using inferior glides will also allow for improvement to adjacent capsular restrictions and benefit mobility of external rotation and abduction. This treatment plan is confirmed by the Rundquist and Ludewig (2004) seminal study.
When this phase is achieved, two home exercise program self- stretches become effective and tolerable (Figures 4 & 5). Case study Idiopathic Adhesive Capsulitis - Left Shoulder Dysfunction This case demonstrates the process of range of motion acquisi- tion and exemplifies an optimal level of sustained weekly ROM improvement. Figure 6 shows the patient’s active external rotation at neutral on the discharge date. All active ROM measurements were taken prior to treatment, directly from the chart (Figure 7).
Figure 6
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