This syndrome is characterized by a loss of motion at the GH joint in all directions.  In most cases, a capsular pattern of restriction is noted and associated with a medical diagnosis of adhesive capsulitis.  This syndrome progresses through three stages.  The patient presentation and treatment may vary, depending on the stage.  GH hypomobility refers to the second two stages. (Sahrmann, 2002)

SYMPTOMS & HISTORY

• Pain in superior, anterior, or posterior shoulder or deltoid area
• Pain may radiate down lateral arm to elbow
• Stiffness and loss of rom
• Unable to sleep on affected side; may awaken frequently
• Common functional limitations:  unable to fasten bra, remove coat, remove shirt overhead, reach behind back
• Most common ages 40-60
• More women than men
• History of trauma
• Diabetes

KEY TESTS & SIGNS

MOVEMENT IMPAIRMENTS

• Loss of both active/passive rom in all directions, most commonly in a capsular pattern
• Typically, pain increases toward the limits of the rom
• Excessice humeral superior glide noted during shoulder flexion and abduction
• Decreased gh__________ just distal to acromiom w/arm overhead
• Compensatory movements:
• During shoulder flexion/abduction scapula elevates excessively
• During shoulder lateral rotation, scapula adducts or depresses
• During shoulder medial rotation, scapula anterior tilts or abducts

SPECIAL TESTS

• Accessory joint motion decreased gh glide in all directions

ASSOCIATED SIGNS

ALIGNMENT AND APPEARANCE

• May have normal resting alignment
• May develop scapular elevation secondary to compensatory motion
• Decreased distance between humeral head and base of neck at end-range arm elevation

IMPAIRMENTS IN MUSCLE RECRUITMENT

• Deltoid dominates over rotator cuff muscles
• Upper trap dominates over lower trap as a result of compensation

IMPAIRMENTS IN MUSCLE LENGTH

• Muscles are probably short but difficult to test initiallybecause of restriction of rom pectoralis, latissimus, medial and lateral rotators
• Long middle and lower middle trapezius

IMPAIRMENTS IN MUSCLE STRENGTH

• Weak rotator cuff muscles

DIFF MVMT & ASSOC DX

DIFFERENTIAL HUMERAL DIAGNOSES

• Rule:  if gh hypomobility exists, it superceded all other dx
• Humeral superior glide

DIFFERENTIAL PRIMARY DIAGNOSES

• Scapular downward rotation
• Scapular abduction

ASSOCIATED DIAGNOSES

• Frozen shoulder
• Adhesive capsulitis
• Rotator cuff tendinopathy
• Shoulder impingement
• Partial or complete rotator cuff tear
• Bicipital tendinopathy
• Supraspinatus tendinopathy or tear
• Bursitis
• Ac joint pain
• Calcific tendinopathy
• Post surgical or post fracture

MED DX REQ. REFERRAL

MUSCULOSKELETAL ORIGIN

• Cervical radiopathy
• Brachial plexus injury
• Rotator cuff tear
• Fracture
• Oa or ra
• Glenoid labrum tear

VICERAL ORIGIN

• Neoplasms
• Cardiovascular disease
• Pulmonary disease
• Breast disease
• Abdominal organ pathologic condition

SYSTEMIC ORIGIN

• Collagen vascular disease
• Gout
• Siphilis and gonnorhea
• Sickle cell amemia
• Hemophilia
• Rheumatic desease

MOVEMENT TX

PRIMARY EMPHASIS

• To teach the patient to dissociate gh motion from st motion…and
• To improve the restricted posterior inferior motion of the humerus while avoiding anterior and superior glide

STAGE 1 TX:

STANDING POSITION

• Perform passive shoulder flexion using uninvolved hand to lift involved arm
• Face and lean slightly into wall…slide ulnar side of handup the wall…use uninvolved hand to complete motion… Stop with onset of pain
• Maintain shoulder in neutral position while attempting to laterally rotate shoulder

SUPINE POSITION

• Abduct arm to 50˚…requires active scapular adduction
• Pec minor stretch
• W/shoulder abducted to 50˚ and a pillow under the arm so the arm is in horizontal flexion, rotate shoulder medially while maintaining strong pressure on humerus to prevent anterior glide

NO PRONE EXERCISES DUE TO PAIN

QUADRUPED POSITION

• Limited backward rocking due to pain

STAGE 2 Tx:

STANDING POSITION

• Perform shoulder flexion facing wall with elbow flexed maintaining shoulder lateral rotation as much as possible

SUPINE POSITION

• Perform shoulder medial rotation with resistance (5 lb.)
• Perform shoulder lateral rotation with resistance (3 lb.)
• Perform shoulder flexion with resistance (3 lb.)

PRONE POSITION

• Perform active-assisted shoulder flexion exerting pressure against floor with opposite hand

QUADRUPED POSITION

• Backward rocking to the point of pain