Shoulder Rehabilitation
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Direct answer
A painful arc between 60 and 120 degrees of abduction with passive range preserved points to subacromial impingement; loss of both active and passive rotation in the capsular pattern points to adhesive capsulitis — separating those two patterns is half of shoulder rehabilitation. Treatment runs from scapular and cuff strengthening for impingement and instability, through graded capsular stretching across frozen shoulder's three phases, to protected, phase-locked protocols after cuff repair and Bankart surgery.
What you must remember
- Cuff testing maps to muscles: empty-can (Jobe) test for supraspinatus, resisted external rotation and hornblower's sign for infraspinatus and teres minor, lift-off and belly-press for subscapularis.
- The abduction arc by muscle: supraspinatus initiates the first 15 degrees, deltoid carries 15 to 90, and trapezius with serratus anterior rotate the scapula beyond 90 — while the impingement painful arc sits at 60 to 120 degrees.
- Neer's impingement stages: stage I oedema and haemorrhage under age 25, stage II fibrosis and tendinopathy at 25 to 40, stage III acromial spur with partial or full-thickness tears over 40; Neer and Hawkins–Kennedy tests screen for it.
- Frozen shoulder phases: freezing (2 to 9 months), frozen (4 to 12 months), thawing (12 to 42 months) — strongly tied to diabetes and thyroid disorder, the illness commonly running one to three years.
- Cyriax's capsular pattern at the glenohumeral joint: external rotation lost most, then abduction, then internal rotation — a pattern restriction separating capsulitis from cuff disease.
- After rotator cuff repair: sling or abduction pillow for about 4 to 6 weeks, passive then active-assisted range first, active movement from about week six, strengthening near week twelve; active abduction and external rotation threaten the repair early.
- Instability lesions: Bankart (anteroinferior labral tear, the classic recurrence lesion of the young dislocator), Hill–Sachs (posterolateral humeral head impaction fracture) and SLAP (superior labrum anterior to posterior, linked to the biceps anchor and Speed's test).
- Acromioclavicular grades I to III are managed mostly conservatively — sling, early gentle movement, progressive strengthening — the cross-body adduction test localising the joint. Scapular stabilisers (serratus anterior, trapezius, rhomboids) underpin all programmes.
Reasoning through a stiff diabetic shoulder
A 52-year-old woman with type 2 diabetes reports four months of progressively painful, stiff right shoulder with night pain that wakes her on rolling onto the side. The discriminator is passive range: active and passive movement are both globally restricted — external rotation barely 20 degrees, abduction 80, the thumb reaching only the ipsilateral hip. Loss of passive range in the capsular pattern plus the diabetic association settles adhesive capsulitis entering its frozen phase — cuff disease would keep passive range full and show a painful arc.
Management follows the phase, not a fixed protocol. Residual painful-phase symptoms are handled gently — prescribed analgesia, pendulum and cane exercises, no aggressive stretching while pain dominates, with physician-directed steroid or hydrodilatation as adjuncts. In the stiff phase she earns graded stretching: sleeper stretches for posterior capsule, towel-behind-back for internal rotation, pulley-assisted elevation, Maitland grades III–IV glenohumeral mobilisations. The thawing phase adds cuff and scapular strengthening. She hears the timeline honestly — many months to resolution, possible residual restriction, the other shoulder following in a meaningful minority — because expectation-setting here is itself treatment.
Where students slip
Active versus passive range is the discriminating skill: capsulitis loses both, cuff pathology loses active while passive stays full — miss it and every vignette is mislabelled. Numbers get scrambled — 15 degrees for supraspinatus, 90 for the deltoid handover, 60 to 120 for the arc — and Neer's stage ages (under 25, 25 to 40, over 40) come as a matching list. The dislocation vignette hides an age trap: the young first-time dislocator risks recurrent instability and a Bankart lesion, while the elderly dislocator tears the cuff or damages the axillary nerve. Post-repair questions punish "active abduction from week two"; the correct instinct is passive protection for the first six weeks.
Frequently asked questions
What is the painful arc and in which condition does it occur?
Pain between roughly 60 and 120 degrees of abduction, typical of subacromial impingement and supraspinatus lesions; above the arc, scapular rotation clears the tendon.
State the capsular pattern of the glenohumeral joint.
External rotation most restricted, then abduction, then internal rotation — Cyriax's pattern of adhesive capsulitis.
Name the three phases of frozen shoulder with their durations.
Freezing (painful) 2 to 9 months, frozen (stiff) 4 to 12 months, thawing (recovery) 12 to 42 months, often longer in diabetes.
Which test examines subscapularis, and how?
The lift-off — hand behind the back, lifted off the lumbar spine against resistance; inability indicates subscapularis weakness.
Why is active abduction avoided early after rotator cuff repair?
Active contraction of supraspinatus and deltoid pulls on the fresh repair; passive and active-assisted motion protect it for roughly the first six weeks.
What is a Hill–Sachs lesion?
A posterolateral impaction fracture of the humeral head from striking the glenoid during anterior dislocation; a marker of recurrence risk.