Patients usually prefer the smooth, repetitive oscillations, which resemble the “bumping” rhythm preferred in Maitland techniques. This type of mobilization is part of the hybrid system of shoulder joint mobilization. The editorial I can’t believe we don’t know that! discusses the need for research into basic questions for patient care (Merrick, 2006). This relates to the seminal study on manual therapy for shoulder stiffness conducted by Rundquist and Ludewig (2004). Using high-tech motion analysis for idiopathic stiffness cases, a pioneer study was performed to confirm what motions and in what sequence should guide shoulder joint mobilization/stretching protocols. This study supported the idea that a physiologic overflow effect causes improvements from a treated capsular direction into an untreated direction. For example, inferior glides can also improve anterior and posterior translation of the joint. Additionally, Johnson (2007) demonstrated that elevation ROM improved to a greater extent with posterior glides versus anterior glides, inferring the dynamics of overflow from treated to untreated areas of the capsule. Nevertheless, findings from various studies determine an optimal pathway to release capsular restrictions in the following sequence: ● Elevation : First and foremost. ● External rotation : Both at neutral and at 90° of abduction. ● Internal rotation : The least important, and focused on later in treatment progression. In reviewing this sequence, elevation is the most critical movement to restore first. The most effective mobilization for that motion is inferior glides. The next most important movement to restore is external rotation, both at neutral and at 90° of abduction. As stated, because of the overflow effect, the early application of inferior glides benefits all planes of mobility. Testing subscapularis flexibility assesses the mobility of passive external rotation at neutral. This emphasized the importance of sustained stretch for the subscapularis to help capsular mobility and functional recovery. The last movement to focus mobilization and stretches on is internal rotation. Early efforts to stretch for adducted or internally rotated positions not only produce pronounced pain but tend to slow recovery of other motions. This study does not disregard internal rotation for function. It recommends focusing on internal rotation ROM later in the rehabilitation process, when it is more tolerable for the patient (Rundquist & Ludewig, 2004). 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.
Figure 3
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. 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.
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