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Manual Therapy 13 (2008) 165–170

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Case Report

Posterior glenohumeral stiffness: Capsular or muscular problem?A case report

Antonio Poser�, Oscar Casonato

Physical Therapy Department, Centro di Medicina, Viale Venezia 91, 31015 Conegliano, Italy

Received 14 April 2006; received in revised form 12 April 2007; accepted 19 July 2007

Keywords: Posterior glenohumeral capsule; Massage; Impingement syndrome

1. Introduction

The impingement syndrome’s aetiology is multi-factorial. The mechanical factors potentially contribut-ing to this pathology are altered neuromuscular control,decreased force of the rotator cuff and peri-scapularmuscles, the acromion’s morphology and posture andstiffness of the posterior capsule (Michener et al., 2003).Amongst these dysfunctions, the authors want to focuson the retraction of the posterior capsule, which can beseen clinically by a limitation in trans-thoracic adduc-tion and internal rotation.

Some authors (Warner et al., 1990; Tyler et al., 2000;Matsen and Artnz, 2004), maintain that a number ofpatients with impingement syndrome show a decreasedtrans-thoracic adduction and internal rotation causedby the thickening and shortening of the posteriorglenohumeral capsule.

From a clinical point of view, Tyler et al. (2000) andLin and Yang (2006) have demonstrated that there is astrict correlation between loss of trans-thoracic adduc-tion and limitation of internal rotation. The relationshipbetween these two limitations is that 1 cm of trans-thoracic adduction corresponds to an internal rotationreduction of 41.

Harryman et al. (1990), in their study on glenohum-eral arthrokinematics, introduced for the first time theconcept of obligate translation. Obligate translation

see front matter r 2007 Elsevier Ltd. All rights reserved.

ath.2007.07.002

ing author. Tel.: +390438661911;

661950.

ress: antposer@libero.it (A. Poser).

means a shifting of the humeral head in the oppositedirection from the capsule–ligament structure that isbeing tensed during the physiological movement. Forexample, during external rotation, the tension from thecapsule and the anterior ligaments provokes a posteriortranslation of the humeral head. The same authors alsonoticed that a surgical shortening of the posteriorcapsule caused an ‘‘abnormal’’ obligate translation inan antero-superior direction during arm flexion. Beforethis one study, Howell et al. (1998) had already observedthis particular obligate translation ‘‘in vivo’’, whilstWerner et al. (2004) and Grossman et al. (2005) confirmthe presence of this on cadaver examination. Recently, ithas been suspected that this particular mechanism(‘‘abnormal’’ obligate translation) is also one of theinducing factors not only for sub-acromial impinge-ment, but also for athletes’ Superior Labral AnteriorPosterior (SLAP) lesions (baseball, volleyball, tennis,swimming, etc.) (Burkhart and Morgan, 1998; Burkhartet al., 2003; Grossman et al., 2005).

Even though on cadaver specimens it has beendemonstrated that a restricted internal rotation andtrans-thoracic adduction is caused by the tensing of theposterior capsule (Ovesen and Nielsen, 1986; Terryet al., 1991; Gerber et al., 2003; Grossman et al., 2005),in a clinical setting it is impossible to selectively isolatethe tension exercised by the posterior capsule from thetension exercised by the infraspinatus and teres minormuscles, making it, thus, impossible to tell exactly whatis the source of the joint restriction.

Excluding the Burkhart et al. (2003) study, whichdemonstrated the presence of a thickened and retracted

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Table 1

Inclusion/exclusion criteria (Lukasiewicz et al., 1999; McClure et al.,

2004; Bullock et al., 2005)

Inclusion criteria

The patient needs to meet at least three of the following criteria

� Presence of Neer’s sign

� Positive Hawkins’ test results

� Painful arc� Pain during palpation of the rotator cuff tendons

� Anterior or lateral shoulder pain

� Painful resisted abduction

Exclusion criteria

� Previous traumas of the shoulder

� Surgical operation around the shoulder area

� Pain originating from the cervical spine

� Frozen shoulder

A. Poser, O. Casonato / Manual Therapy 13 (2008) 165–170166

capsule in professional baseball pitchers playing formany years, there is no anatomical or histological studythat can demonstrate the presence of this type ofalteration in individuals affected by impingementsyndrome.

The achievement of functional recovery of jointinternal rotation is common practice nowadays bothas a treatment result in impingement syndrome casesand as a prevention strategy for athletes (Litchfieldet al., 1993; Kamkar et al., 1993; Johansen et al., 1995;Burkhart et al., 2003), even though the conclusiveevidence of its efficacy is limited (McClure et al., 2004;Aina and May, 2005).

In particular, the McClure et al. (2004) study hasdemonstrated the existence of a positive relationshipbetween the improvement of joint internal rotation andfunctionality in patients with impingement syndrome.

It seems, therefore, that complete internal rotationneeds to be a clinical pre-requisite for normal gleno-humeral kinematics and functionality. Even though it iswidely accepted that muscular problems may be thecause of a ROM limitation, as regards to a decrease ininternal glenohumeral rotation, today’s literature claimsit is caused by a stiffness of the posterior capsule.

This case report (and the ongoing study) the authorsare presenting was born from our doubt that a restrictedinternal rotation could only be caused by a retraction ofthe posterior part of the capsule. This study was basedon the hypothesis that limitations in the glenohumeraljoint internal rotation may be caused, more or lesssignificantly, by a contracture of the infraspinatus andteres minor muscles.

2. Case report

2.1. History

A 42-year-old male manual worker came to theauthors complaining of right shoulder pain, which hadpersisted for 12 weeks. The symptom’s onset wasinsidious. The intermittent pain was caused andaggravated by moving the arm beyond 901—of elevationor by—sleeping on the right side. The pain intensity wasnot so strong as to interfere with working activities andwhen needed the patient would use NSAIDS and icepacks to alleviate pain. The whole of the shoulder waspainful (particularly in the deltoid area), but there wasno radiation. The patient did not suffer any pain aroundthe cervical area or in the upper extremity. No othersignificant findings were noted during any part of thehistory.

2.2. Objective examination (assessment)

The examination did not show any differenceson shoulder muscle trophism or significant postural

asymmetries. Scapulo-humeral rhythm was harmonic,although at the end of the movement there was evidenceof a slight restriction of right elevation, with moreelevation towards the top of the scapula and painappearing at the end of the movement. Passive jointrange of motion only showed a restricted internalrotation of the right shoulder in abduction at 901compared to the left shoulder. Manual muscular testsrevealed no weaknesses, although resisted abductionprovoked pain. Impingement tests were positive, parti-cularly Hawkins’ (Hawkins and Kennedy, 1980) andYocum’s tests (Yocum, 1983). The active compressiontest was also positive (O’Brien et al., 1998).

The cervical spine did not show any movementrestrictions or pain during the articular assessment andboth the Spurling (Spurling and Scoville, 1944) andQuadrant test (Maitland, 1986) in extension, lateralflexion and same side rotation proved negative.

The sub-acromial impingement diagnosis was con-firmed by the patient’s symptomatology matching theinclusion/exclusion criteria identified by many authors(Lukasiewicz et al., 1999; McClure et al., 2004; Bullocket al., 2005) (see Table 1).

3. Measurements and treatment

Before treating the patient, internal rotation jointrange of motion was measured with the patient lyingsupine and with the arm held in 901 abduction.Measurements were taken with an inclinometer. Theforce applied by the physiotherapist to internally rotatethe arm was measured with an electronic dynamometerattached to the patient’s wrist, while a second phy-siotherapist fixed the scapula to prevent shoulderanteposition (Awan et al., 2002) (Fig. 1). The forceused for pre- and post-treatment measurements wasidentical. Resisted muscle tests in abduction, internaland external rotation, were done as described by Cyriax(Ombregt et al., 1995). The resulting force was measured

ARTICLE IN PRESSA. Poser, O. Casonato / Manual Therapy 13 (2008) 165–170 167

with a dynamometer in order to use the same values forthe control test. Lastly, impingement tests (Yocum’s andHawkin’s) and the active compression test (O’Brienet al., 1998) were done. This test, originally conceivedfor differentiating an AC lesion from a SLAP lesion, hasbeen considered extremely useful because it tenses thewhole of the posterior structure through trans-thoracicadduction, internal rotation and flexion of the humerus.Theoretically, this particular position should cause agreater obligate translation of the head of the humerus.Parentis et al. (2004) noted that the active compressiontest in its first part brings the supraspinatus tendontowards the acromion, making this test similar toimpingement tests. Even for these tests, the resultingforces were measured with a dynamometer so they couldbe reproduced exactly during following control tests.Pain provoked by these tests was measured using avisual analogue scale (V.A.S.) immediately after com-pletion of the tests.

In order to treat only the muscle part of the shoulderwithout affecting the capsule, the patient was positionedprone with the arm held by his side in a relaxed position.

Fig. 1. Measurement of internal rotation range and force.

68

78 78

0

10

20

30

40

50

60

70

80

90

100

deg

rees

1° pre 1° post 2° pre

internal r

Fig. 2. Internal rotation measurement

The patient was given a 7min massage of theinfraspinatus and a 3min massage of the teres minor.The authors considered that this time of massage wassufficient to have a change in the muscle. The massagewas done only over the areas of the infraspinatus thatwere contracted and painful to palpation and on thewhole of the teres minor (given its small size), movingthe fingertips in a circular fashion (Fig. 2). The forceapplied was related to the patient’s capacity to endurepain.

All of the prior measurements were retaken oncompletion of the treatment. The treatment consistedof three sessions given on alternate days. During thisweek of treatment the patient did not take anymedication or change his daily routine. Furthermore,he did not receive any other treatment or practice anyexercise at home.

4. Results

After the three treatment sessions, joint range ofmotion in internal rotation had increased by 201, withthe initial excursion being 681 and the final range 881(Fig. 3).

A clear V.A.S. improvement was visible for all ofthe administered tests. Resisted abduction decreasedfrom an initial 2.8 to 0; Hawkin’s from 3 to 0.3;Yocum’s from 3 to 0.1 and active compression from 2.3to 0 (Fig. 4).

5. Discussion

The treatment results obtained for this clinical caseshow how a restricted internal rotation may be causedby the posterior muscle component rather than by aretraction of the posterior capsule.

The results obtained from treatment of the painfulcomponent of the impingement tests (Hawkin’s andYocum’s) and the active compression test, support thehypothesis that the excess of obligate translation may be

8278

88

2° post 3° pre

otation ROM

before and after each treatment.

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0

1

2

3

1 pre

V.A

.S.P

ain

Resisted abduction

Hawkins test

Active compression test

Yocum test

3.5

2.5

1.5

0.5

Treatments

1 post 2 pre 2 post 3 pre 3 post

Fig. 3. V.A.S. for the various tests: resisted abduction, Yocum test,

Hawkins test and active compression test.

Fig. 4. Infraspinatus massage.

Fig. 5. (A) Asymmetrical tension of the supraspinatus tendon (arrows)

caused by the excessive tension of infraspinatus. (B) After the

treatment the infraspinatus tendon is relaxed and the tension inside

the supraspinatus tendon is distributed in a well-blended way; IS:

infraspinatus; SP: supraspinatus; SC: subscapularis.

A. Poser, O. Casonato / Manual Therapy 13 (2008) 165–170168

caused by the shortening of the posterior structures(capsule/muscles). These tests, in fact, stimulate thosestructures in a peculiar manner, because they requireparticular flexion/internal rotation/thoracic adductionmovements. Therefore, it is fair to assume that thedecrease in pain may be caused by a decrease of theobligate translation and consequently by a decrease ofthe posterior muscular component.

Lastly, it is also interesting to note that the painprovoked by the resisted abduction had diminished.This improvement, though, is not attributable to theobligate translation phenomena as for the other tests,because the test is done in 20–301 of abduction in asituation in which there is no tensing of the posteriorstructure. This phenomenon could be explained by

assuming that retraction of the posterior muscles keepsthe head of the humerus in a slight external rotation,which in turn tenses the anterior part of the supraspi-natus tendon and relaxes the posterior part (see Fig. 4).During arm movement this phenomena could provoke abigger mechanical stimulation of the anterior part of thesupraspinatus tendon. This difference in tension be-tween anterior and posterior fibres of the supraspinatustendon in relation to the rotation state of the humeralhead has been demonstrated by Nakajima et al. (2004).When, through treatment, the tension exercised by theinfraspinatus/teres minor is decreased, the humeral headgoes back to its correct position, promoting thus auniform distribution of tensions within the supraspina-tus tendon (see Fig. 5). Reduction of pain duringresisted abduction tests could also be attributable to adecrease of the tension transmitted by the infraspinatustendon to the supraspinatus tendon, as a result of amuscular relaxation achieved through the massagetechnique. It is, in fact, well known that there is acertain degree of fusion between the rotator cuff’stendons (Clark and Harryman, 1992) (see Fig. 6) andthis fact leads the authors to believe that a contractureof one of the rotator cuff’s muscles could create animbalance and therefore a bigger tension of the varioustendinous parts that compose the rotator cuff.

Another possible explanation of the pain reductioncould be the gate control effect due to the massage, butthis phenomenon cannot quite prove the decreasing ofthe pain until the following treatment.

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Fig. 6. Rotator cuff tendon embrication. In particular, it is evident

that supraspinatus posterior fibers and infraspinatus cranial fibers

converge. IS: infraspinatus; SP: supraspinatus; SC: subscapularis; BG:

bicipital groove; LT: lesser tubercle; GT: greater tubercle.

A. Poser, O. Casonato / Manual Therapy 13 (2008) 165–170 169

The massage was done on all of the areas, which feltcontracted and painful during palpation, keeping thepatient’s arm in a neutral position and without puttingany kind of stress on the joint capsule. The particulartechnique adopted by the authors gave results in jointexcursion at every session. Ten minutes were sufficientto verify whether the joint deficit could have been causedby a muscular dysfunction or by a capsular problem.This technique can therefore represent a quick diag-nostic tool for evaluating the dysfunctional state of thesupraspinatus and teres minor muscles. A similar, oreven greater result may be obtained using other manualor neuromuscular techniques, but the fact remains thatthe authors were able to treat the patient withoutstressing the joint capsule using this specific technique.This massage represents a rapid tool for recognizing thepresence of a joint restriction which is likely to bemuscular in origin.

6. Conclusions

This case report suggests that by massaging theinfraspinatus and teres minor muscles it was possibleto gain 201 of internal rotation in a patient withimpingement syndrome. This leads the authors tobelieve that an internal rotation deficit could also becaused by a contracture of the muscles and notexclusively by a posterior capsule rigidity. It is obviouslynecessary to do further studies on a large number ofcases to confirm this hypothesis and calculate theincidence of the muscular component versus thecapsular component. A larger study is now underwayto confirm the hypothesis.

Acknowledgments

We sincerely thank Mr. Phil McClure and MarcoTesta for the critical analysis and the helpful hints onthis manuscript.

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