appropriate. If pain is resolved but joint stiffness is still present, increased forces are required and most beneficial. Joint mobilization, combined with prolonged static stretch, are two main treatment strategies frequently used to address shoulder joint stiffness. Physical therapy is described as the foundation of frozen shoulder treatment. Research recognizes the medical communities’ reliance on physical therapy as the initial treatment for conservative care of shoulder stiffness (Pandey, 2021, 2022). Joint mobilization is one of the most frequently used interventions in most physical therapy treatment sessions. Joint mobilization techniques will monopolize a majority of the available in-clinic time for the early stages of frozen shoulder and adhesive capsulitis. With joint mobilization methods, there is overall lack of standardization. Clinicians currently demonstrate a variation of joint mobilizations techniques. There are significant inconsistencies with timing and duration of joint mobilization treatments. Most notably, manual therapy training differs greatly, leading to irregularity in individual therapist skill. This section will investigate the research of the many determinants of effective joint mobilization to develop an evidence-based clinical session format and define optimal ROM acquisition progress. It is valuable for clinicians to review the different components of joint mobilization treatment, such as hand positioning, amplitude and quality of glides, and other preparatory aspects. The goal is to introduce a hybrid treatment approach that incorporates different manual therapy techniques. Studies support the specific efficacy of joint mobilization, both as an adjunct to other shoulder stiffness treatments or as a singular intervention (Conroy, 1998; Dierks, 2004; Favejee, 2011; Green, 2003; Hanchard, 2010; Jewell, 2009; Kelley, 2009; Kumar, 2016; Levine, 2007; Nicholson, 1985; Page, 2016; Steuri, 2017; Tanaka, 2010; Yang, 2012). Several other studies have provided specific guidelines on position, quality and amplitude of joint mobilization techniques. These provide clinicians with a reference point to maximize success within the clinic. These studies identify the importance of placing the contracted capsule in a loose pack position with initial joint mobilizations. When we consider the anatomy of a shoulder joint capsule, the goal of mobilization is to deliver stretch loads to all areas of the capsule. Hsu (2000) determined the efficacy of applied mobilization at the end-range, regardless of direction. However, it is suggested that early mobilization glides should concentrate on the anterior- inferior segment (Conroy, 1998; Hsu, 2000; Hurschler, 2001; Johnson, 2007; Lin, 2007; Nicholson, 1985). Lin (2007) found that the loose pack position was at 40° of abduction and slight external rotation, closely related to the plane of the scapula. This is the optimal position to initiate light stretches to the anterior-inferior shoulder joint capsule, as translation movements are maximized. Additionally, it was found the optimal position for rotational freedom was from 40-60° of abduction (Lin 2007). This concept was expanded on, with evidence that freest position for external rotation occurs at 60° of abduction (Hurschler, 2001). The combination of these positions creates the composite measure for joint mobilization: 40° of abduction (Ludewig, 2004). The next component of effective mobilization involves the amplitude of glides. Initial mobilizations are applied in the Grade 2-3 range (within the freest motion on the joint) and graduate to Grade 4 (with a light force to the capsular end-feel and quick release). These grades are dependent on patient tolerance. The quality of the glide is also something to consider; i.e., short and forceful or smooth and repetitive. 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. 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.
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