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How to Know When to Push a Stiff and Painful Shoulder

If you have ever worked with someone with a stiff and painful shoulder, you know how challenging it can be to gain motion.  Regardless of if this is a postoperative shoulder, someone that gets tight from shoulder impingement, or someone with adhesive capsulitis, push too hard or too fast often backfires and causes them to get worse!

One of the more common questions I get from students and new clinicians is – “how do you know when to push range of motion.”

Luckily, there is a pretty simple way to knowing when to push a stiff and painful shoulder and when to back off.

Assess End Feel

How to Know When to Push a Stiff and Painful ShoulderIn addition to assessing the quantity of motion, you should also assess the quality of motion.  This is essentially the “end feel,” or the quality of the end range of motion.

Every joint has a normal end feel.  Some common examples are:

  • Boney: Hard end feel of two bones approximating.  Elbow extension is a good example.
  • Capsular or Ligamentous: Often described as stretching a piece of leather.  This is normal joint end feel, such as with shoulder external rotation
  • Muscular: This is more like stretching a piece of rubber, like when stretching the hamstrings
  • Tissue Approximation: When the mobility is stopped because you run out of room to move, such as during elbow or knee flexion.
  • Empty: Pain does not allow you to get to the end of the range of motion, you stop in the middle of the range.
  • Spasm: An abrupt end of the movement that feels as if the person is in pain and guarded.  This feels like the muscles are stopping the motion and spasming.

Don’t Push Through a Spasm End Feel

A simple rule I have always followed and has helped me know when to push motion with a painful and stiff shoulder is to never push through a spasm end feel.

If someone presents with a spasm end feel, your primary treatment objective should switch from trying to gain motion to trying to reduce spasm.  Attempting to push through the spasm almost always backfires.

You’ll know you can push harder when the spasm end feel changes to a capsular end feel.  That’s your cue to get more aggressive.  But…  be careful!  It’s possible to push too hard or too fast again and revert back to a spasm end feel.

Learn How I Treat the Stiff Shoulder

If you are interested in mastering your understanding of the shoulder, I have an amazing online program teaching you exactly how I evaluate and treat the shoulder!

shoulder seminarThe online program at takes you through an 8-week program with new content added every week.  You can learn at your own pace in the comfort of your own home.  You’ll learn exactly how I approach:

  • The evaluation of the shoulder
  • Selecting exercises for the shoulder
  • Manual resistance and dynamic stabilization drills for the shoulder
  • Nonoperative and postoperative rehabilitation
  • Rotator cuff injuries
  • Shoulder instability
  • SLAP lesions
  • The stiff shoulder
  • Manual therapy for the shoulder

The program offers 21 CEU hours for the NATA and APTA of MA and 20 CEU hours through the NSCA.

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5 Principles of Treating the Stiff Shoulder

5 Principles of Treating the Stiff Shoulder

The latest webinar recording for Inner Circle members is now available below.

5 Principles of Treating the Stiff Shoulder

This month’s Inner Circle webinars discussed several principles of treating the stiff shoulder.  We’ll cover:

  • The several types of “stiff shoulders”
  • Are we seeing shoulder stiffness more than we realize?
  • How to completely understand the anatomy and biomechanics of the glenohumeral capsule
  • Know when to push motion (and when not to!)
  • What should people with stiff shoulders do at home between sessions

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

Identifying Early Signs and Symptoms of Adhesive Capsulitis

image In my opinion, one of the most challenging disorders of the shoulder to properly diagnose during the early stages is adhesive capsulitis, or frozen shoulder.  Let me explain that further – once a person has global tightness and loss of motion, this is a pretty easy diagnosis. 

But I often wonder if some of our patients with “shoulder pain” but not loss of motion may actually have stage one irritation of the capsule that could develop into adhesive capsulitis. 

If we can work with patients during this phase, maybe we can stop the process?  Maybe we can prevent severe loss of motion?  Unfortunately to date, there has been many anecdotal advice but no consensus on the clinical identifiers or early stage adhesive capsulitis.

A recent article in the Journal of Physical Therapy sought to develop a consensus among a group of experts regarding clinical identifiers for the first stage of adhesive capsulitis (Abstract here or if you are a subscriber of PT you can view full article here)  The author’s used the Delphi technique (more information on the Delphi Technique here) to poll a group of experts within the fields of rehabilitation medicine, physical medicine, orthopedic surgery, physical therapy, chiropractic, and osteopathy. 

After polling and statistical analysis, the authors report 8 factors that the group agreed upon as being strong clinical indicators of early stage adhesive capsulitis:

  • There is a strong component of night pain
  • There is a marked increase in pain with rapid or unguarded movements
  • It is uncomfortable to lie on the affected shoulder
  • The patient reports the pain is easily aggravated by movement
  • The onset is generally in people greater than 35 years old
  • On examination, there is global loss of active and passive range of motion
  • On examination, there is pain at the end range of motion
  • There is a global loss of passive glenohumeral joint movement

These factors were all selected and narrowed down from an original list of 60 items that is included in the manuscript.  I thought it was interesting that many of the clinical identifiers that I use did not make the final consensus.  For example, none of the below reached consensus:

  • The onset is generally in people less than 60 years old
  • The condition more commonly presents in females
  • There can be an association with diabetes

Perhaps these are stereotypes that I have used in my practice based on past anecdotal advice. 

 

Clinical Implications

The results of this study in no way should be used as strict criteria in the diagnosis of adhesive capsulitis, but may provide some useful guidance during the subjective and objective portions of your exam.  I would suggest integrating the above information into your examination. 

I always recommend that you carefully exam someone that comes to you with “shoulder pain”   to try to identify signs and symptoms of early stage adhesive capsulitis.  As we all know, this pathology can have severe complications on the individual’s functional status, anything we can do to identify and prevent the progression would be extremely helpful.

 

 

Walmsley S, Rivett DA, & Osmotherly PG (2009). Adhesive capsulitis: establishing consensus on clinical identifiers for stage 1 using the DELPHI technique. Physical therapy, 89 (9), 906-17 PMID: 19589853