The Use of Glenohumeral Joint Mobilizations for a Patient Status Post Rotator Cuff Repair: A Case Report

Adam Fritsch, SPT; Dr. Chris Hurley, PT, DPT, DSc, OCS, SCS, ATC

Background and Purpose

According to the American Academy of Orthopedic Surgeons (AAOS) between 1998 and

2004 over 5 million physician visits were due to rotator cuff (RTC) problems, a forty

percent increase in the same time period.1 Literature has shown as we age past 40 the

incidence of RTC tears goes up as a result of degeneration of the tendon.1-2 In the

general population five to forty percent of individuals over the age of 60 have evidence

of a full thickness RTC tear.2 Rotator cuff tears can lead to debilitating pain and an

increase in functional limitations.3 The goal of a RTC repair is to improve pain, range of

motion (ROM), strength and function.3 Patients who undergo a RTC repair present with

multiple impairments including increased pain, decreased strength, range of motion

(ROM), proprioception, and motor planning. Because of these impairments the patient

is limited in their ability to perform functional reaching activities, which may result in a

decline in their general health status.2 Due to the ever aging population and with the

Baby Boomer generation entering their sixties it’s reasonable to conclude the number of

RTC repairs will go up in the future.1

Because of these reasons the postoperative rehabilitation program becomes critical in

the success of surgically repaired RTC.4 A number of rehab protocols that exist today are

based purely on anecdotal clinical observation and the best rehabilitation program that

allows for greatest tendon to bone healing while preventing shoulder stiffness does not

exist.4-5 With a repair of the RTC, shoulder joint contractures may occur.6 Because of this

ROM exercises as well as joint mobilizations (JM) are indicated.6 To prevent and treat

joint contractures it is common practice to use limited movement of the joint during

ROM exercises.6 When this treatment intervention is painful it becomes very difficult to

stretch the connective tissue that limits motion.6 However, JM can be used to stretch

these tissues while reducing pain and increasing ROM.6-7 Current literature has shown

some support for the use of JM for the treatment of subacromial impingement, which

has been linked to increased risk for RTC tears.8-9 However, little evidence exists looking

at JM and their use with patients recovering from a post op RTC repair. It’s possible

many orthopedic surgeons are hesitant to include joint mobilizations in their post op

protocols for fear of excess strain on the repair site and therefore may prefer a more

conservative approach. Muraki et al in 2007 looked at the strain on a repaired

supraspinatus tendon during manual traction and translational glide mobilizations to the

GH joint on fresh cadavers.6 They found when grade III JM were done with the arm

abducted greater than 30 degrees strains on the tendon were less than 0.5kg.10 It is

possible the surgical intervention does not correct the mechanical abnormality that

contributed to the pathology, for example capsular tightness. Capsular tightness has

loosely been associated as a risk factor for GH impingement.11-12 Joint mobilizations

have been shown to be successful in the treatment of capsular tightness and the

resolution of impingement related symptoms.11-12 Because JM may be indicated in the

treatment of subacromial impingement and surgical intervention may not fully correct

the mechanical abnormality that may contribute to RTC pathology, JM may be beneficial

in the treatment of RTC repairs. Therefore, the purpose of this case report is to describe

the use and outcomes of glenohumeral (GH) JM for a patient status post RTC repair.

Case Description

The patient was a 79-year-old left-handed male who presented to the clinic 6 weeks

after a right RTC repair with subacromial decompression and biceps tenodesis. The

patient reported he had been having trouble in his right shoulder on and off for 52 years

with no trauma or direct injury. However, 4 months prior to therapy he sustained a fall

causing injury to the right shoulder. The patient had his rotator cuff repaired

approximately 2 1/2 months after his fall. He was required to wear a sling for 4 weeks

following the surgery and had the sling discharged two weeks prior to his evaluation at

therapy. The patient was instructed by the physician to ice and perform pendulum

exercises, shoulder shrugs, elbow flexion/extension and grip strengthening prior to

reporting to physical therapy. Patient admitted he had not been icing and was only

performing ball squeezes and shoulder shrugs at home. He stated an overall feeling of

stiffness in the shoulder that made it difficult for him to perform certain movements. His

report of pain was 9/10 with movement and 1-2/10 with rest using the visual analog

pain scale (VAS).13 The patient denied any numbness or tingling. The patient’s self

reported functional limitations at the time of the initial evaluation were putting his right

hand on the steering wheel; putting on clothes without compensation; tucking in his

shirt; reaching behind or overhead to bathe and perform daily hygiene; and sleep on his

right side. The therapist used the patient specific functional scale (PSFS) to rate these

functional limitations, with 0 being unable to perform and 10 being able to perform the

activity the same as before surgery.14 The patient rated his ability to perform these

functions as 0/10. The patient’s past medical history was significant for type 2 diabetes,

cardiovascular disease, Parkinson’s disease, several herniated discs in the lumbar spine,

two angioplasties, cholecystectomy, and deficits in hearing for which he wore hearing

aids. The patient admitted to taking 1-2 tablets of 5-325mg Norco at night to help him

sleep otherwise he was taking extra strength Tylenol for day pain. Patient’s goals for

physical therapy were to regain full movement, decrease his pain and increase his

strength so he could return to all functional activities at home. Written informed

consent was obtained from the patient.

Clinical Impression #1

The patient was demonstrating signs and symptoms consistent with being 6 weeks

status post RTC repair with subacromial decompression and bicep tendonesis. The

patient’s primary complaints were pain with movement specifically in the frontal plane,

stiffness in the left shoulder, and the inability to perform activities of daily living (ADL’s).

The patient was selected for this case report secondary to him being 6 weeks status post

following a RTC repair with subacromial decompression and biceps tendonesis and

because he was experiencing pain and stiffness as a result of the surgery. Because of

this, further tests were required specifically looking at ROM, general observation of

movement, and using functional subjective scales including the patient specific

functional scale (PSFS), shoulder pain and disability index (SPADI) and the disabilities of

the arm, shoulder and hand (DASH). The patient’s past medical history is significant for

diabetes and Parkinson’s disease and the original injury leading to the surgery was a

result of the patient falling so a neurological foot and balance screen was also

performed. The patient’s past medical history being remarkable for diabetes puts him at

risk for adhesive capsulitis and because the patient was experiencing difficulty with

movement as a result of stiffness and pain, JM was indicated at this time to begin

assisting in pain modulation and ROM.15

Examination

Tests and measures were performed at initial evaluation, 3 weeks and 7 weeks when

the student physical therapist’s clinical rotation ended. Administrations and tests were

carried out by the student physical therapist (A.F.) under the supervision of the clinical

instructor (C.S.). The questionnaires that were administered were: (1) the patient

specific functional scale (PSFS), (2) shoulder pain and disability index (SPADI), (3) and the

disabilities of the arm, shoulder and hand questionnaire (DASH).14,16 All questionnaires

were considered to be reliable and valid measures.16 The physical tests consisted of a

neurological foot screen per the physician quality and reporting initiative (PQRI)

required for all Medicare patients with a history of diabetes; timed up and go test

(TUG); and ROM in GH flexion, abduction, external rotation, and internal rotation

measured with a 1 degree increment Baseline plastic goniometer. Light and sharp touch

sensation was assessed using a standard cue tip and paperclip respectively, assessing L4,

L5, and S1 dermatomes. The patient was asked if they felt the sensation and if it was

different between the left and right foot. Cutaneous sensation was tested using a

Semmes-Weinstein 5.07 monofilament, which exerts 10 grams of force when it is bowed

into a C-shape. Patients who are unable to detect application of this force are

considered to have lost protective sensation. Cutaneous sensation was tested at 12

sites on both the plantar and dorsal aspect of the foot (see appendix A). Proprioception

was measured by grasping the 1st distal interphalangeal joint (DIP), refraining from

touching the nail bed and moving the DIP into flexion and extension asking the patient if

the toe was up or down. Vibration was assessed using a Baseline 128Hz tuning fork.

The patient was asked if he felt the vibrations and to notify the therapist when they

stopped. Vibration was tested at both the 1st DIP and lateral malleolus. Deep tendon

reflexes (DTRs) were assessed using a Taylor reflex hammer and testing both L3 and S1

reflexes. Manual muscle testing was performed at the ankle for dorsiflexion, plantar

flexion, inversion and eversion. The TUG was assessed as defined by Podsialdo et al.17

Manual muscle testing was not performed on the GH joint at initial evaluation as it was

contraindicated at that time. Active ROM was measured by having the patient sit for

flexion and abduction and lay supine for internal and external rotation. Passive ROM

was measured in supine for all planes.

Clinical Impression #2

The patient demonstrated both decreased active and passive ROM at the right GH joint

when compared to the left. The patient also reported pain with active movement at the

right GH joint in flexion and abduction. During passive ROM it was noted the patient

had end range guarding and capsular tightness in all planes. Because the patient was

demonstrating decreased passive ROM, capsular tightness and pain with movement, he

was appropriate for JM to be used as an intervention. The patient had a TUG time of 20

seconds, which puts him at an increased fall risk with 14 seconds being the cut-off. The

patient also had diminished light and sharp touch along dermatomes L4, L5, and S1

bilaterally. Monofilament testing showed decreased protective sensation along the

plantar aspect of the left foot. Proprioception was intact bilaterally. Vibration was

diminished bilaterally in the DIP of the 1st ray and lateral malleoli. Finally, the patient

was given a grade of 0 for both L4 and S1 DTR’s meaning there was no reflexive

response observed. Due to the patient’s TUG time and decreased sensation; balance

was incorporated in his plan of care.

Intervention

Manual therapy (see appendix B)

Every treatment session began with a moist hot pack for ten minutes to the right

shoulder in order to help with muscle relaxation and tissue extensibility.18 The patient

then laid supine on the plinth while the therapist performed anterior, posterior, inferior

glides and long axis distraction to the GH joint. Glides and distractions were performed

with the patient’s arm abducted between fifty-five and seventy degrees to achieve open

packed position, elbow flexed and the patient’s hand resting in the therapist’s axilla.19

For the anterior glide the therapist’s hands grasped the humerus just distal to the GH

joint and applied an anterior directed force to the posterior aspect of the proximal

humerus. For the posterior glide the therapist grasped the proximal humerus and

applied a posteriorly directed force to the anterior aspect of the proximal humerus. The

inferior glide consisted of the mobilizing hand grasping the proximal humerus and

applying an inferiorly directed force to the long axis of the humerus. Finally, for long

axis distraction the therapist grasped the proximal humerus with both hands and

applied a distraction force along the long axis of the humerus. For the first two weeks of

treatment the therapist only applied grade II JM per MD protocol to resist stressing the

suture site. The remaining 5 weeks grade III-IV JM were applied based on capsular

hypomobility. Each mobilization was applied for thirty seconds at a rate of one

mobilization per 1-2 seconds with a rest of thirty seconds in between. The mobilization

of thirty seconds followed by a thirty- second rest was repeated three more times for a

total of four repetitions. Glenohumeral JM was performed at the beginning of every

treatment session throughout the patient’s episode of care. After the mobilizations the

therapist performed passive range of motion into flexion, abduction, external and

internal rotation to the patient’s perceived tolerance or resistance was felt. After the

JM and passive range of motion the patient performed active ROM and therapeutic

exercises based on his tolerance and progression. Progression was determined through

re-assessments taken at the end of each week of strength using manual muscle testing

or active ROM, and pain level using the VAS as well as the provided MD protocol.

Therapeutic Exercise

Along with JM the patient performed various therapeutic exercises in order to address

the other impairments resulting from the RTC repair. Exercises consisted of active

assisted ROM using the pulleys into both flexion and scaption. The patient was asked to

perform this for 2 minutes holding for approximately five seconds at end range each

time. The patient also performed active assisted flexion and abduction using a 55cm

stability ball and rolling it along a table and up a wall. Strengthening consisted of bent

over rows; bent over GH extension; side-lying external rotation, flexion and abduction;

prone lower trapezius, mid-trapezius and rhomboid exercises; wall and counter push-

ups; supine serratus punches; and standing GH ER, IR, extension and scapular retraction

with thera-bands. The amount of repetitions and sets was determined based on the

most up to date physical activity recommendations which state individuals should

perform 8 to 10 strengthening exercises of the major muscle groups twice or more per

week.20-21 For an untrained individual it is recommended they perform, a volume of 4

sets, and a frequency of 2 to 3 times per week.22-23 Based on these recommendations

the patient was asked to perform 3 sets of 8 repetitions for the strengthening exercises.

Because the patient was at a fall risk established by his TUG time and decreased

sensation along the plantar aspect of his feet, balance was incorporated into his plan of

care. The patient was required to perform many of the therapeutic exercises while

standing with a small base of support, tandem stance or standing on a foam pad in

order to help improve his stability.24 After each treatment session the patient was set

up on interferential current and ice for 15 minutes, continuous, at 80-150mHz in order

to assist in pain modulation.25

Home Exercise Program (HEP)

The patient was initially started with a HEP that included passive shoulder flexion of the

right upper extremity (UE) using the left UE for assistance in supine; GH external

rotation from neutral with a cane and patient in supine; table slides for GH flexion with

patient sitting; and scapular squeezes to begin parascapular strengthening and proper

posturing during overhead reaching. The patient was instructed to perform five

repetitions of each of these four times a day. As the patient’s passive and active range

of motion progressed and he reached 8 weeks post op, isometric strengthening was

added. The patient was instructed to perform isometric submaximal strengthening by

pushing into a towel roll against a wall for GH flexion, extension, abduction, adduction,

external rotation and internal rotation. At approximately 10 weeks resisted GH

extension and scapular retraction were added with theraband. At 12 weeks the patient

was performing maximal isometric contractions in GH flexion, abduction, and adduction;

standing resisted GH external and internal rotation with theraband with his arm at his

side; scapular protraction in supine; abduction and flexion active ROM in sidelying; and

wall pushups. HEP was progressed based on the patient’s tolerance and strength as well

as per MD protocol. There was difficulty in progressing the patient’s exercise program

however, due to lack of progress in both strength and ROM at the affected GH joint.

One of the issues that may have contributed to this lack in progress was the patient’s

sub-optimal compliance with his HEP and icing schedule, to which the patient admitted.

Many times sub-optimal compliance and icing following a rotator cuff repair has

resulted in slower progress being seen in both strength and ROM based on the student

physical therapist’s experience.

Outcomes

The patient attended 14 treatment sessions and canceled 2 during the student physical

therapists 7-week clinical rotation. In that time the patient subjectively reported

feeling much better overall, and felt he was 70% improved since initiating therapy. For

the PSFS (see table 1) he rated his ability to drive with his hands at 10 and 2 on the

steering wheel as 6/10; reaching overhead with his right arm as 6/10; lifting groceries

from floor to chest height as 10/10; carrying groceries as 10/10; sleeping on his right

side as 0/10; and putting on his jacket or sweater without compensation as 6/10. This

puts his overall PSFS score as 6.3/10 indicating he is approximately 60% of his normal

functional status. This was an increase from 0% at baseline and 25% at 3 weeks with a

minimum detectable change being 2 points for a 90% confidence interval.14 The patients

SPDAI score (see table 2) improved from 45 to 26.6 at 3 weeks and to 24.6 at 7 weeks.

The patients DASH score (see table 3) improved from 50.8 to 45.8 at 3 weeks and to

28.3 at 7 weeks. The minimum detectable change is 13 points for the SPADI for 90%

confidence interval and 12.7 points on the DASH for a 95% confidence interval.26-

27 Based on this the patient improved on both subjective outcome measures. The

patient rated his overall pain level as a 4/10 as compared to 9/10 at baseline. The

patients TUG improved from 20 seconds to 11 seconds, which is considered significant

due to the minimum detectable change being 3.5 seconds. Finally, the patients active

ROM, passive ROM, and strength all improved (see table 4).

Discussion

This purpose of this case report was to describe the use of GH joint mobilizations for a

patient status post RTC repair. The patient did show improvement as evident by his

PSFS, SPADI and DASH scores, all of which were considered statistically significant. The

patient’s pain level decreased overall and his active ROM, passive ROM, and strength all

improved.

Manual therapy has been shown to improve passive and active ROM as well as decrease

pain in painful shoulder conditions.28 The purpose of JM is to restore normal functional

mobility and arthrokinematics of the joint by increasing the extensibility of the capsular

tissue.29 Additionally JM is intended to reduce pain, improve collagen realignment and

break up adhesions by stimulating mechanoreceptors and reducing muscle spasms and

guarding due to nociceptive stimulation.29 These effects are purely hypothetical and no

evidence exists to support these mechanisms. Little evidence exists in how joint

mobilizations can be used as part of a comprehensive post op RTC protocol. Literature

suggests capsular tightness is a potential contributing factor to subacromial

impingement possibly leading to RTC pathology and is something that may not be

addressed with surgical intervention.11-12 When a patient is in significant pain as is the

case following a RTC repair, stretching of the tissues while attempting to reduce the

chance of an increase in pain is optimal. Joint mobilizations have been shown to help

address capsular tightness, reduce pain and possibly improve ROM of the joint.6-7,11-12,29

The patient in this case report presented with decreased ROM, decreased strength, and

intermittent pain throughout his rehabilitation. Joint mobilizations were used in

conjunction with other therapeutic exercises, manual therapy and modalities to address

these impairments. Because this is a case report cause and effect cannot be established

between the use of these interventions and the patient’s positive outcomes. It may be

possible the use of JM in combination with other active and passive movements during

rehab aided in causing capsular extensibility, which allowed the patient to achieve

greater ROM. Another possibility is JM and therapeutic exercises may have helped to

break up scar adhesions that might have formed following the surgical procedure. The

patient’s ability to produce strength also improved. Literature has shown the presence

of painful symptoms may inhibit motor outflow, therefore, decreasing the ability of the

muscle to activate.30 It’s possible the application of JM helped in decreasing the

patient’s pain by reducing muscle spasm and guarding which may have allowed him to

increase his ability to move actively, thereby putting increased demands on the

musculature and eventually improving his strength.

Other factors may have contributed to these outcomes. We cannot discount time in the

decrease of the patient’s pain and improvement in the PSFS, DASH and SPADI. The

patient did not begin therapy until 6 weeks after surgery. This would put the patient

hypothetically in the inflammatory to proliferative phase of healing because we must

consider delayed tissue healing as a result of his history of diabetes. As the patient

progresses through these phases of healing symptom resolution could possibly occur

simply from the passage of time even without intervention. As the patient moves

further out from surgery and initial movement precautions are dropped, gains in

strength and ROM could be seen simply from performing more movement with the

surgical shoulder. A limitation of this case report was the difficulty in determining if the

appropriate grade had been applied during the mobilization. The process of applying a

proper JM depends on the therapist’s ability to perceive the resistance that he or she is

feeling.31 As a student physical therapist the ability to perceive this resistance is

something that may not be adequate.

Conclusion

The postoperative rehabilitation program is critical in the success of a surgically repaired

RTC. Many impairments come about as a result of RTC repairs including increased pain,

decreased ROM and strength. The ability to decrease the patient’s pain while increasing

their ROM is imperative in order for the patient to return to their functional activity and

improve their quality of life. Glenohumeral JM may be a tool that can help patients post

RTC repair achieve these outcomes in conjunction with a comprehensive rehabilitation

program. The patient in this case report achieved both positive subjective and objective

results following a 7-week physical therapy program, which included GH joint

mobilizations. Further research is needed in the effectiveness of JM performed on

patients with postoperative RTC repairs. Randomized control trials would be beneficial

in this case to determine if the intervention of JM in patients with RTC repairs would

result in positive outcomes. Further studies may look at if patients who have undergone

a RTC repair would progress faster if JM were introduced as compared to a control.

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Table 1

Patient Specific Functional Scale (PSFS) Scores (0-10) Θ at Baseline, 3 and 7-week re-assessment.

Activities Baseline 3 weeks 7 weeks

Lifting groceries from floor to chest height 0 0 10

Sleep on R side 0 0 0

Dress without compensation into jackets and sweaters

0 2 6

Carry groceries at side 0 10 10

Drive with hands at 10 and 2 positions on steering wheel

0 3 6

Reach overhead with R 0 0 6

Total Score 0 15/6=2.5 38/6=6.3

Θ 0=unable to perform activity, 10=able to perform activity at the same level as before surgery

Table 2

Shoulder Pain and Disability Index (SPADI) Scores (0-100) at Baseline, 3 and 7-week re-assessment. Dimension Item Baseline 3 weeks 7 weeks

PainΘ How severe is your pain?

At its worst? 7 4 4

When lying on the involved side?

0 - 4

Reaching for something on a high shelf?

7 7 5

Touching the back of your neck?

2 0 1

Pushing with the involved arm?

- 0 0

DisabilityΒ How much difficulty do you have?

Washing your hair? 10 0 0

Washing your back? 10 10 10

Putting on an undershirt or jumper?

3 0 2

Putting on a shirt that buttons down the front?

0 0 1

Putting on your pants?

0 0 0

Placing an object on a high shelf?

9 9 4

Carrying a heavy object of 10 pounds?

2 2 1

Removing something from your backpocket?

3 0 0

Total SPADI scoreΧ 45 26.6 24.6

Θ0=no pain, 10=worst pain imaginable, did not answer (-); Β0=no difficulty, 10=so difficult it requires help;Χ0=no disability, 100=disabled

Table 3 The Disabilities of the Arm, Shoulder, and Hand (DASH) Scores (0-100) at Baseline, 3 and 7-week re-assessment. Dimension Item Baseline 3

weeks

7 weeks

Functional Limitations

Please rate your ability to do the following activities in the last week?Π

Open a tight or new jar Mid Mid Mod

Write Mod ND ND

Turn a key ND ND ND

Prepare a meal ND Mid ND

Push open a heavy door Mid Mod ND

Place an object on a shelf above your head

Mod U Mid

Do heavy household chores

U U ND

Garden or do yard work U U U

Make a bed Mod Mid ND

Carry a shopping bag ND ND ND

Carry a heavy object (over 10lbs)

Mid Mid ND

Change a lightbulb overhead

Mod U U

Wash or blow dry your hair Mod ND ND

Wash your back Mod U U

Put on a pullover sweater U ND ND

Use a knife to cut food Mid U ND

Recreational activities which require little effort (cardplaying, knitting)

ND ND ND

Recreational activities in which you take some force or impact through your arm, shoulder, or hand (golf, hammering)

U Mod Mod

Recreational activities in which you move your arm freely (Frisbee, badminton)

U U U

Manage transportation needs

ND ND ND

Sexual activities U Mod Mod

During the past week to what extent has your arm, shoulder, or hand problem interfered with your normal social activities with family, friends, neighbors, or groups?

Quite a bit Slightly Not at all

During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder, or hand problems?

Very limited

Very limited

Slightly limited

Pain Please rate the severity of the following symptoms in the last week?

Arm, shoulder or hand pain

Moderate Mild Mild

Arm, shoulder or hand pain when you performed any specific activity

Mild Mild Mild

Tingling in your arm, shoulder, or hand

None None None

Weakness in your arm, shoulder, or hand

Severe Severe Severe

Stiffness in your arm, shoulder, or hand

Extreme Severe Moderate

During the past week how much difficulty have you had sleeping because of pain in your arm, shoulder, or hand?

Mod Mod ND

I feel less capable, less confident, or less useful because of my arm, shoulder, or hand problem

Agree Agree Agree

Total DASH scoreΧ 50.8 45.8 28.3

Χ0=no disability, 100=disabled; ΠND=no difficulty, Mid=mild difficulty, Mod=moderate difficulty, SD=severe difficulty, U=unable

Table 4 Glenohumeral Strength, Passive, and Active Range of Motion (ROM) of the Target Shoulder (Right) and Contralateral Shoulder at Baseline, 3 week and 7 week re-assessment

Test Baseline 3 weeks 7 weeks

Right Left Right Left Right Left

Glenohumeral ROM (°) (Active/Passive)

Flexion 20/90 140/NA 30/115 140/NA 55/165 140/NA

Abduction -/- 145/NA 55/65 145/NA 65/110 145/NA

External Rotation

-/30 (from neutral)

C5/- 50/52 (at 60° ABD)

C5/- 60/70 (at 90° ABD)

C5/-

Internal Rotation

-/able to lie hand on stomach

L1/- 60/70 (at 60° ABD)

L1/- 60/60 (at 90° ABD)

L1/-

Glenohumeral Strength (Manual muscle grade)

Flexion C 4/5 2+/5 4/5 3-/5 4/5

Abduction C 4/5 2+/5 4/5 3-/5 4/5

External Rotation

C 4/5 2+/5 4/5 3-/5 4/5

Internal Rotation

C 4/5 2+/5 4/5 3-/5 4/5

(-)=unable to test, NA=did not test, C=Contraindicated

Appendix A

Diabetic Foot Sensation Testing Locations

Appendix B

Inferior Glide Posterior Glide Anterior Glide Long Axis Distraction