To make sound clinical decisions when managing patients with shoulder disorders, it is necessary to understand the various pathologies, surgical procedures, and associated precautions and to identify presenting impairments, functional limitations, and possible disabilities.

JOINT HYPOMOBILITY: NONOPERATIVE MANAGEMENT

Glenohumeral Joint

Restricted mobility of the glenohumeral joint may occur as a result of pathology such as rheumatoid arthritis or osteoarthritis, from prolonged immobilization, or from unknown causes (idiopathic frozen shoulder). Associated impairments in mobility and muscle performance also occur in the muscles and other connective tissues in the area.

Related Pathologies and Etiology of Symptoms

Rheumatoid arthritis and osteoarthritis.

Traumatic arthritis. This disorder occurs in response to a fall or blow to the shoulder or to microtrauma from faulty mechanics or overuse.

Postimmobilization arthritis or stiff shoulder. This disorder occurs as a result of lack of movement or secondary effects from conditions such as heart disease, stroke, or diabetes mellitus.

Idiopathic frozen shoulder. This disorder, which is also called adhesive capsulitis or periarthritis, is characterized by the development of dense adhesions, capsular thickening, and capsular restrictions, especially in the dependent folds of the capsule, rather than arthritic changes in the cartilage and bone, as seen with rheumatoid arthritis or osteoarthritis. The onset is insidious and usually occurs between the ages of 40 and 60 years; there is no known cause (primary frozen shoulder), although problems already mentioned in which there is a period of pain and/or restricted motion, such as with rheumatoid arthritis, osteoarthritis, trauma, or immobilization, may lead to a frozen shoulder (secondary frozen shoulder). With primary frozen shoulder, the pathogenesis may be a provoking chronic inflammation in musculotendinous or synovial tissue such as the rotator cuff, biceps tendon, or joint capsule. Consistent with this is a faulty posture and muscle imbalance predisposing the suprahumeral space to impingement and overuse syndromes.

Clinical Signs and Symptoms
Glenohumeral joint arthritis. The following characteristics are associated with glenohumeral (GH) joint pathologies that lead to hypomobility.

• Acute phase. Pain and muscle guarding limit motion, usually external rotation and abduction. Pain is frequently experienced radiating below the elbow and may disturb sleep. Joint swelling is not detected owing to the depth of the capsule, although tenderness can be elicited by palpating in the fornix immediately below the edge of the acromion process between the attachments of the anterior and middle deltoid.

• Subacute phase. Capsular tightness begins to develop. Limited motion is detected, consistent with a capsular pattern (external rotation and abduction are most limited, and internal rotation and flexion are least limited). Often, the patient feels pain as the end of the limited range is reached. Joint-play testing reveals limited joint play. If the patient can be treated as the acute condition begins to subside by gradually increasing shoulder motion and activity, the complication of joint and soft tissue contractures can usually be minimized.

• Chronic phase. Progressive restriction of the GH joint capsule magnifies the signs of limited motion in a capsular pattern and decreased joint play. There is significant loss of function with an inability to reach overhead, outward, or behind the back. Aching is usually localized to the deltoid region.

Idiopathic frozen shoulder. This clinical entity follows a classic pattern.

• “Freezing.” Characterized by intense pain even at rest and limitation of motion by 2 to 3 weeks after onset. These acute symptoms may last 10 to 36 weeks.

• “Frozen.” Characterized by pain only with movement, significant adhesions, and limited GH motions, with substitute motions in the scapula. Atrophy of the deltoid, rotator cuff, biceps, and triceps brachii muscles occurs. This stage lasts 4 to 12 months.

• “Thawing.” Characterized by no pain and no synovitis but significant capsular restrictions from adhesions. This stage lasts 2 to 24 months or longer. Some patients never regain normal ROM.

Some references indicate that spontaneous recovery occurs, on average, 2 years from onset, although others have reported long-term limitations without spontaneous recovery. Inappropriately aggressive therapy at the wrong time may prolong the symptoms. Management guidelines are the same as for acute (maximum protection during the freezing stage), subacute (controlled motion during the frozen stage), and chronic (return to function during the thawing state).

Common Impairments
• Night pain and disturbed sleep during acute flares

• Pain on motion and often at rest during acute flares

• Mobility: decreased joint play and ROM, usually limiting external rotation and abduction with some limitation of internal rotation and elevation in flexion

• Posture: possible faulty postural compensations with protracted and anteriorly tipped scapula, rounded shoulders, and elevated and protected shoulder

• Decreased arm swing during gait

• Muscle performance: general muscle weakness and poor endurance in the glenohumeral muscles with overuse of the scapular muscles leading to pain in the trapezius and posterior cervical muscles

• Guarded shoulder motions with substitute scapular motions

Common Functional Limitations/Disabilities

• Inability to reach overhead, behind head, out to the side, and behind back; thus, having difficulty dressing (such as putting on a jacket or coat or women fastening undergarments behind their back), reaching hand into back pocket of pants (to retrieve wallet), reaching out a car window (to use an ATM machine), self-grooming (such as combing hair, brushing teeth, washing face), and bringing eating utensils to the mouth

• Difficulty lifting weighted objects, such as dishes into a cupboard

• Limited ability to sustain repetitive activities

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