With increased inferior glide motion, patients will demonstrate improvements in elevation and active external rotation ROM. The functional goal of active external rotation of 90°, at 90° of abduction, is the capacity of an uninjured, normal shoulder. The ability to perform this movement is demonstrated by the “Goalpost Test”. The name of this test comes from the fact that the patient’s arms resemble a goalpost seen on a football field. As the capsular restrictions improve, the joint mobilizations are then adjusted to apply forces at the newly acquired end range. Hence, the ROM acquisition progression is achieved. The image shows the sequential adjustments performed by a clinician during a gradual joint mobilization progression. Phases 1-6 in Figure 3 illustrate the progression of positions for joint mobilizations. Phase 1 depicts early inferior glides near the plane of scapula for the most restricted joint capsule. Phase 2 reflects inferior glides near 90° of abduction. Phases 3 & 4 show inferior glides at 90° of abduction with the addition of external rotation. 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 acromioclavicular joint is usually restricted in the settled stage of any prolonged shoulder stiffness case. When Phase 4 is achieved, several key milestones are present: 1. Patients likely have restored daily functional movement, with minimal daily pain periods. 2. This position correlates to active ROM for elevation from 120- 140° and external rotation of 45‑50° at 90 ° of abduction. 3. It signals the readiness of the patient to tolerate isolated posterior glides and more aggressive static stretches for internal rotation. 4. Active ROM at this level is a sign that further invasive treatments, such as MUA and surgery, are not indicated. 5. 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
When this phase is achieved, two home exercise program self- stretches become effective and tolerable (Figures 4 & 5). 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 mobilizations and stretches protects against common pain flare-ups and allows for overall improved capsular mobility. Figure 4: External Rotation
Figure 5: Internal Rotation
Evidence-based practice: Early applications of stretching 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.
Case study Idiopathic Adhesive Capsulitis - Left Shoulder Dysfunction This case demonstrates the process of range of motion acquisition 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).
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Book Code: PTNY1024
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