"The Effect of Anterior versus Posterior Glide Joint Mobilization on External Rotation range of motion in patients with Shoulder Adhesive Capsulitis."
Typically, External Rotation is the most limited motion in patients with adhesive capsulitis. The traditional manual therapy technique for these patients was an anterior glide mobilization to help increase external rotation ROM. This treatment was well accepted for a number of years because it agrees with the arthrokinematic principles. In recent years, there has been new evidence surfacing about the beneficial effects of posterior mobilizations for this patient population.
In this article, the authors found that using a posterior glide mobilization (Kaltenborn Grade III sustained), with therapeutic ultrasound and upper extremity therapeutic exercises was the most effective for increasing external rotation ROM deficits in patients with adhesive capsulitis. They found that the posterior mobilization group had an average increase of 31.1 degrees of external rotation (after 3 treatment sessions), compared to only 3 degrees average for the anterior mobilization group.
The article also found that patients with adhesive capsulitis often had a decreased rotator cuff interval space, pushing the humeral head anterior/ superior and not allowing normal posterior/ inferior motion. We must remember that at the glenohumeral joint, both anterior and posterior forces must be in coordination for proper stability.
Anatomy and Kinesiology Review:
Superior Glenohumeral Ligament:
Taut in adduction, inferior and a/p translations of the humeral head.
Middle Glenohumeral Ligament:
Taut in anterior translation of the humeral head, especially in 45-60 d. of abduction; external rotation
Inferior Glenohumeral Ligament (has 3 parts):
Axillary pouch: taut in 90 d. abduction, combined with a/p and inferior translations.
Anterior band: taut in 90 degrees abduction and full external rotation; anterior humeral translation.
Posterior band: taut in 90 d. of abduction and full internal rotation.
Taut in adduction; inferior translation of the humeral head; external rotation
Very informative. But if it is asked in the National Physical Therapy Exam. which answer will they consider correct in improving the shoulder external rotation? Anterior glide (ref: Kisner/Colby) or Posterior glide (accdg to latest research)? :-)
Posterior glide for ER (due to arthrokinematic motion of the humeral head when gliding during ER). Although the anterior capsule is stretched--- it is gliding in a lateral and posterior direction- therefore posterior mobilization of the GH joint is most effective in increasing patient's ER who has adhesive capsulitis.
I am not sure about Daniel's response to the above question. Practice exams suggest anterior glide is most appropriate for ER. This makes sense given the anterolateral arthrokinematics of the GH joint during external rotation in a neutral position. However, clinically we might see tight posterior capsules more often. This position may decrease external rotation given the anteriorly displaced position of the humeral head where the anterior capsule is on stretch and both ant. and post. structures are not in the optimal position for humeral rotation. I would agree with Daniel's response clinically, but for the exam, stick with Kisner and Colby!
Interestingly enough, the OCS prep course I am using suggests posterior glide to address decreased ER (pasted):
a. Posterior glides Correct: The glenohumeral joint does not comply with strict concave-convex rules due to capsular constraint. The humeral head needs to have enough capsular mobility available to posteriorly translate on the glenoid during external rotation. This concept was supported in a recent RCT, which found greater improvements in ER with posterior gleno-humeral glides.
Did your prep course provide a reference?
Note that the difference in elevation could play a role in this as well. Per Current Concepts of Orthopaedic PT shoulder, pg 45: The CLC (capsoligamentous complex) should be viewed using a circle concept. The circle concept refers to all regions of the CLC providing stability in all directions..... Therefore, improved extensibility of any portion of the CLC results in improved motion in all planes.
the assumption seems to be that the joint capsule is the primary limiter (maybe lax anteriorly, tight posteriorly), but what about a guarded/hypertonic subscapularis? The fact that there was such a large increase in ROM over a short time seems less likely due to deforming collagen (which is incredibly hard to stretch) and more like there was a neurophysiologic reduction in subscap guarding due to the increased mechanoreceptor input on the posterior capsule and maybe decreased input from the anterior capsule. On the contrary, I would expect that pushing an already anteriorly placed humeral head into further anterior translation would cause more guarding of the subscap hence no benefit.
oh and my comment is not directed at any specific person already replied above.
another thought, is that in a newer study therapeutic US is one of the treatments associated with a poorer outcome from adhesive cap. although i'm hoping most are not putting their confidence in US as being helpful anyway
i was reading that the study used the finding that ER PROM did NOT improve with increased abduction to exclude subscap guarding patients, but i don't see where they actually palpated it to build the case. in addition, pec minor is often tender and guarded, and that would increase anterior tilting and humeral head translation anteriorly. bottom line, the "joint rules" are just guides, but if have to actually assess the joint arthrokinematics and surrounding structures for every joint and not make assumptions. ok i'm done. :)
Nice blog Dr. Schwabe!
Recently taking a O'Sullivans practice exam in the newest edition, the book had this exact question for this exact patient population. The answer was Posterior Glide. The reasoning was this was the one exception to the convex-concave rule. So it seems like if this is a question on the NPTE, then Posterior would be the correct answer based on the latest studies published. Good to know clinically by the way and great blog.
The most recent edition of the Scorebuilder's study book also had a question related to this in their first practice exam, and the answer was an anterior glide, referencing Kisner p. 549. Which I got wrong, after taking the O'Sullivan practice test Greg mentioned above and it stating a posterior glide was the way to go. So I'll just hope this question does not come up on the actual NPTE :)
And the now newest version of Scorebuilders (2018) still says anterior glide is the answer to increase ER, with a reference to Kisner (p. 134)
Anterior glide to improve ER
But in Adhesive capsulitis case-- posterior glide to GH to improve ER.
So, when they specifically talk about Adhesive capsulitis -- we would give Posterior guide to GH in order to improve ER which is an exception to concave convex rule.
But in general shoulder conditions-- we would follow concave convex rule and give anterior glide to GH to improve ER.
Stick to this concept even for NTPE exam too.
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