The Stiff Shoulder
Kevin L. Smith MD
Stiffness of the shoulder is a very debilitating problem. Regardless of underlying cause, people with tight shoulders invariably complain of pain and dysfunction. Almost all have difficulty sleeping, especially on side of the stiff shoulder, but also on the other side as well as sometimes on their backs. If severe, patients may have to sleep in a reclining chair in order to be comfortable. Many people with stiff shoulders complain of pain at rest and with use of the arm, and most are limited in their activities simply because of diminished shoulder motion. They are unable to reach over head, unable to reach across their body to wash the back of the opposite shoulder, and unable to reach behind their back to tuck in their shirt.
There are multiple causes for shoulder stiffness. Adhesive capsulitis or frozen shoulder is a significant cause of stiffness that comes on gradually, with no apparent cause, effects all degrees of motion and can cause severe stiffness. It is “self limiting”, meaning that it should eventually get better over time (possibly up to 2 years), however in the meantime it can be significantly disabling and painful. Other types of shoulder stiffness can be linked to a specific preceding event. These include Post Traumatic Shoulder Stiffness in which there was an injury to the shoulder that initiated the loss of motion. Oftentimes this is due to an immobilization of the shoulder that is either conscious (e.g. holding the arm in a sling for several weeks following a shoulder dislocation of fracture) or unconscious (e.g. a person not using or moving the shoulder for several weeks after an injury because of pain or fear of further injury). Regardless of the type of accident or the actual underlying injury, the stiffness in the shoulder and accompanied pain is often the most significant problem. Post Surgical Shoulder Stiffness is loss of motion secondary to scarring following shoulder surgery. This can oftentimes bring about a dense loss of motion that is difficult to stretch.
Many times there are underlying problems that bring about stiffness, make it persist, or make it hard to rehabilitate. Calcific tendonitis is a calcium deposit that forms in the rotator cuff tendon and can become extremely painful, causing a loss of shoulder use and subsequent loss of shoulder motion. It can remain painful, making it difficult to rehabilitate the shoulder. A partial thickness rotator cuff tear can be quite painful, again causing the initial loss of motion as well as difficulty with rehabilitation. Full thickness or complete rotator cuff tears do not cause loss of shoulder motion in and of themselves. In fact, patients with massive rotator cuff tears oftentimes have excessive shoulder motion. Stiffness may be present along with a full thickness rotator cuff tear but it is not the tear that it causing the stiffness. By only fixing the tear, the shoulder will be made even stiffer. Therefore if stiffness is present in the face of a confirmed complete rotator cuff tear, the stiffness must be addressed first and motion restored before the tear is fixed. Since we know that almost all stiff shoulders are painful and disabled, overcoming the stiffness itself may greatly improve the comfort and function of the shoulder. Abnormal healing (malunion) following a shoulder fracture may lead to a sharp bony block to shoulder motion. This type of lost shoulder motion usually can only be taken care of surgically.
Regardless of the underlying cause or problem that initiated the stiffness or is causing it to persist, the first step of management should be shoulder stretching (except possibly in stiffness associated with fracture malunion). While this stretching is ordered by the physician and can be monitored by a physical therapist, it is the patient who must be in charge of his or her own rehabilitation. The patient should perform their stretching exercises up to 5 times everyday, which is certainly more than they could ever see a therapist. Also, the thought is that the patient is “their own best therapist” in the sense that only the patient can feel the point when a stretch is occurring, and hold that point, just before they reach the point of painful stretch. The therapist does not have this internal feedback mechanism and therefore they may stretch to the point of pain. The therapist should teach the exercises and monitor their performance and success, while the patient is the one who should perform and control them. Throughout the rehabilitative process it is important for the physician, the therapist and the patient to keep in mind that it is the shoulder stiffness that is the main problem and that this must be addressed and corrected before an emphasis is placed on strengthening the shoulder.
Specific exercises for stretching the stiff shoulder include: 1) Forward elevation, 2) External rotation, 3) Cross body adduction, and 4) Internal rotation behind the back. Each exercise should be performed slowly with an emphasis on relaxing the muscles in the shoulder. When the arm reaches a position where motion becomes limited but before pain is felt, an attempt should be made to relax the muscles and gain a few more degrees of motion. At the point of maximum motion the arm should be held for a count of thirty while again trying to maximize relaxation. Each of the described exercises should be performed 5 times during each session with 5 sessions done each day.
Forward elevation (overhead reach) is performed in the supine position (lying flat on your back) or standing, grasping the wrist or elbow of the stiff shoulder with the hand of the other arm, pulling up toward the ceiling and reaching overhead as high as possible (Figure 1). At the point of maximum stretch the arm should be held for a count of thirty.
Figure 1
Another method of performing forward elevation is done sitting next to a counter or table with the stiff arm resting on the table. The patient should then passively lean forward, sliding their arm along the table and thus forward elevating the shoulder (Figure 2). Again, at the point of maximum stretch the shoulder should be held for a count of thirty.
Figure 2
External Rotation (rotation away from the body)is performed in the supine position as shown below (or standing), the stiff side elbow held against or close to the side and flexed to 90 degrees. A stick is held in both hands or the wrist of the stiff shoulder is grasped by the other hand. The unaffected extremity then pushes on the stiff arm to externally rotate it as far as possible while the elbow is kept at the side (Figure 3). Again an attempt should be made to obtain complete relaxation and the arm should be held at the point of maximum external rotation for a count of thirty.
Figure 3
Another method for obtaining external rotation involves standing in an open doorway or against a door, grasping the door frame or handle with the stiff side hand while holding the elbow against the body in 90 degrees of flexion. The patient then rotates their body away from the door frame until they reach the point of stiffness (Figure 4). Again relaxation is maximized and the maximum stretch is held for a count of thirty.
Figure 4
Internal Rotation is performed standing. While grasping the wrist of the involved arm with the other hand, the hands are lifted up the back as high as possible. Again, relaxation should be stressed with the hand held at the highest level of internal rotation for a count of thirty to maximize motion. A towel can also be used to assist with pulling the involved arm into internal rotation behind the back (Figure 5).
Figure 5
Cross Body Adduction is performed sitting or standing, grasping the elbow of the involved arm with the other hand. The involved arm is relaxed and with the elbow extended, it is pulled across the body until a stretch is felt (Figure 6). The cross body stretch should be performed at shoulder level (as is shown in figure 6), at nipple level as well as at eye level. At the maximum stretch the arm is held for a count of thirty.
Figure 6
Once again, each exercise should be performed five times during each session, with 5 sessions done each day. Since no special equipment is required these exercises can be performed almost anywhere at anytime. It must be kept in mind that the exercises should only be performed to the point of maximum stretch, just before the point of pain. If the shoulder becomes too painful the patient will not be able to perform all of the exercises during each session not to mention performing five sessions a day. If the shoulder is significantly irritated in between sessions the stretches should be backed off somewhat in the next session so that all of the sessions can be done.
Patient performed stretching can be an extremely effective and rewarding method for the management of shoulder stiffness. However, it may take several weeks for the exercises to show results and a judgment should not be made on their effectiveness before six weeks of consistent rehabilitation. While most patients can overcome their shoulder stiffness through these exercises, a few may suffer from persistent stiffness despite diligent therapy. This may be secondary to severe scarring or an underlying problem that is limiting rehabilitation. Regardless of the cause, if the patient is sufficiently frustrated with their stiffness and has made a good effort at therapy, surgery may be indicated. This may involve only arthroscopic release of adhesions or may require open excision of dense scar tissue or bone.