SHOULDER ANATOMYFROZEN SHOULDER THE TERT PRINCIPLE

Amy Monroe, Josh Davidson, and Daniel Woodward

East Tennessee State UniversityInternship II – VA Medical Center

4/28/14

SHOULDER FACTS

• The shoulder has the greatest range of motion of any joint in the body.

• Conditions as diverse as liver abscesses, gallstones, gastric ulcers, splenic rupture, pneumonia, and pericarditis can all cause shoulder pain.

SHOULDER OSTEOLOGY

3 Bones

• Clavicle

• Scapula

• Humerus

CLAVICLE

SCAPULA

SCAPULA

HUMERUS

HUMERUS

HUMERUS

ROTATOR CUFF

• Supraspinatus

• Infraspinatus

• Subscapularis

• Teres Minor

Anterior View

Posterior View

MUSCLES OF SCAPULOTHORACIC JOINT

Elevators

• Upper Trap

• Levator Scapulae

• Rhomboids

Depressors

• Lower Trap

• Latissimus Dorsi

• Pec Minor

• Subclavius

Protractors

• Serratus Anterior

GH CAPSULAR LIGAMENTS

• Superior GH Ligament

• Middle GH Ligament

• Inferior GH Ligament

• Coracohumeral Ligament

ADHESIVE CAPSULITIS

WHAT IS IT?

• Adhesive capsulitis- Nevaiser first defined it in 1945 as “the inflamed and fibrotic condition of the capsuloligamentous tissue.

• Codman described it as “frozen shoulder” as “a condition difficult to define, difficult to treat, and difficult to explain from the point of view of pathology.”

• Currently it is considered to be both an inflammatory condition as well as a fibrosing condition

• Adhesive capsulitis of the shoulder (726.0)

FROZEN SHOULDER

PREVALENCE

● 2-5.3% of general population

● Nearly 19% of all patients with diabetes.

● 13.4% of pts with adhesive capulitis had thyroid disfunction

● 5-34% risk for opposite arm involvement

● Can occur bilaterally up to 14% of time

ETIOLOGY AND PATHOLOGY● Unknown

–Trauma

–Inflammation

●Evidence identifies elevated serum cytokine levels.

●Can lead to excess accumulation and production of fibroblasts

releasing type 1 and type III collagen.

●Chronic inflammatory cells and fibroblasts

● 2 categories–Primary

–Secondary

PRIMARY VS. SECONDARY

PRIMARY CHARACTERISTICS

● Insidious, progressive onset of pain

● Women 40-60

● Significant night pain

● Significant limitations of active and passive shoulder motion in more than 1 plane

● Inability to sleep on involved side

● May have tenderness to palpation over supraspinatus or LH of biceps tendon

● End ranges painful

SPECIAL TESTS

● Capsular pattern–ER>abduction>flexion>IR

● Global loss of AROM/PROM

● Capsular integrity–Sulcus sign at 0 and 90

–Ant load and shift

–Post load and shift

● Impingement–Hawkins-Kennedy

–Neers

ROTATOR CUFF

• 62% of idiopathic adhesive

capsulitis were found to have

partial thickness tear of

Supraspinatus

Yoo et al Orthapaedics 2009;32(1):22

ROTATOR INTERVAL● Capsular tissue bwtn

Subscap and

Supraspinatus

● Contribute to stability of

shoulder by limiting

inferior translation and ER

● Contracture of RCI is

present with adhesive

capsulitis

STAGES OF FROZEN SHOULDER• Stage 1

● First 3 months

● Pain progressive

● Loss AROM/PROM

● Exam under anesthesia

near normal ROM

● Arthroscopy:

Hypervascular synovitis

• Stage 2 (freezing)

● 3-9 months

● Persistent pain

● Progressive loss motion

● Exam under anesthesia

moderate improve in ROM

● Arthroscopy: perivascular

scar, fibroplasias

STAGES OF ADHESIVE CAPSULITIS• Stage 3 (frozen)

● 9-14 month

● Reduced pain

● Global limitation of ROM

● Rigid end feel

● ROM doesn't change with

anesthesia

● Arthroscopic: Fibrotic

synovium, no

hypervascularity

• Stage 4 (thawing)

● 15-24 month

● Minimal pain

● Slow recovery of ROM

● Minimal data available for

exam under anesthesia

● Natural course can take 1-

3 years

DIAGNOSIS● Rule in:–Pt is 40-65 years old,

–Pt reports gradual pain and stiffness

●Worse in evening and night

–Pain and stiffness limit functional activities

– Global loss of active/passive ROM

–Loss of ER with arm at pt's side

–Loss of passive ER important b/c typically problems of rotator cuff

doesn't result in loss PROM

–End range movt reproduce same pain

DIAGNOSIS

● Rule out:–PROM is normal

–Radiographic evidence of GH arthritis

–Arthrography: loss shoulder jt volume, thickened capsule

–ULTT reproduces shoulder pain

– Posterior Shoulder Dislocation: ER ROM similarly decreased combined

with a limitation in overall shoulder ROM. Differentially diagnosed with

axillary lateral x-ray reveals dislocated humeral head

RECENT EVIDENCE

● Not been able to conclude which treatment technique, physical therapy,

home exercise program, cortisone injection, manipulation, or surgery, is

most effective.

● Grey: complete recovery in 2 years

JBJS Am 1978;60(4):564

● Miller: normal function and minimal pain after 4 year after home therapy

Orthopaedics 1996;19(10):849-853

EVIDENCE CONT.

• 94% of idiopathic frozen shoulder recover to normal level, range of

motion, function without treatment Vastamaki et al CORR 2012;470(4):1133.43

• Binder et al performed a prospective study (n = 40) on patients with

adhesive capsulitis found that after 3 years 40% of pt's had not regained

normal ROM

Ann Rheum Dis. 1984;43:361-364.

NONSURGICAL REHABILITATION 1,7,3

Stage I

• Goal: Reduce inflammation, symptom management, and patient education

• MD Intervention: Intra-articular injection of corticosteroid combined with anesthetic

• PT Interventions:

a) Patient education

b) Modalities to decrease pain, grade I or II joint mobs, and pain free AAROM.

c) Exercises: Pendulums, pulleys, and other AAROM exercises. HEP!

d) No aggressive PROM/joint mobs

Stage II

• Goal: Continued symptom management and inflammation reduction with more focus on minimizing capsular adhesions

• MD Intervention: Intra-articular injections + NSAIDs

• PT Interventions:

a) Continued patient education, modalities, and AAROM

b) Initiation of grade III joint mobs and PROM stretching as tolerated by patient

c) Continued emphasis placed on frequent performance of the HEP for AAROM stretching

NONSURGICAL REHABILITATION7

Stages III and IV

Goal: Increase both PROM and AROM

MD Intervention: Intra-articular injections and NSAID's no longer indicated

PT Intervention:

a) Low-load, long duration capsular stretching

b) Grade IV joint mobilizations/manipulations

c) TERT

d) AROM strengthening

Creep Grade IV Mobs

TERT End Range Strength

LOW LOAD LONG DURATION STRETCH 3,13

Viscoelasticity

• Muscles, ligaments, and peri-articular structures exhibit viscoelastic properties

• Viscous component – Tissue that deforms and stays deformed permanently 

• Elastic component - Tissue that returns to original length when force is removed

Why is this important?

• Allows for creep and stress-relaxation to occur with loads applied over a period of time

• Creep: Low load long duration stretch = Time dependent deformation

• Stress-relaxation: Decreased tensile stress over time when a body under tensile stress is held at a fixed length

Biologic Principle:

• Peri-articular connective tissues will remodel over time in response to the type and amount of physical stress they receive, while muscles subjected to a prolonged stretch too will lengthen by adding sarcomeres

Issue with short duration stretching utilizing creep and stress-relaxation

• Duration of stretch is NOT long enough to allow for remodeling

• Lengthening is transient with no permanent deformation occurring

• Considered as more of a stretch than a growth

TERT PRINCIPLE 3,10,12

Goal: To achieve plastic deformation

• A state in which tissue will remain elongated upon the removal of a stress, and one that is characterized as being permanent

TERT (total end range time) – Defined as the total amount of time that a joint spends at or near the end of it's available range.

• Treatment method introduced in the late 90's used for decreasing structural stiffness

• Intensity x duration x frequency

• 20 minute duration, 3 x/day frequency = 60 minutes/day (Optimum total TERT time)

Biologic Principle: Collagenous tissue responds to increased tensile loading by synthesis of collagen and collagen will become oriented parallel to the line of stress applied (Davis's Law of soft tissue remodeling)

TERT PROTOCOL 2,9,11

1. Begin with 10 minute active metabolic warm-up aimed to increase collagen tissue temperature

• UBE, rowing machine, or repetitive theraband activities

2. First TERT: Passive warm-up using modalities with the extremity maintained in a stretched position

• Duration should be 10-20 minutes at the maximal amount of stretch tolerated by patient

3. Following first 20 minute TERT session, grade IV joint mobilizations should be provided for the anterior, inferior, and posterior capsule

4. AROM strengthening

• Multiple-angle isometrics and short arc exercises applied within these new ranges

5. Second TERT: Utilize ice with the joint maintained in its maximal stretch position for 10 to 20 minutes

6. HEP to include AAROM stretching, flexibility exercises, and rotator cuff and scapulothoracic muscle strengthening

TERT

FLOWERS ET AL. 2012Purpose: To test validity of the TERT theory

• 15 subjects with 20 PIP flexion contractures between 15 and 20º

• All contractures resulted from primary orthopedic conditions

• Two Groups

• Group A: Wore an initial resting cast x 2 days, had 15 minutes of preconditioning, wore a continuous extension cast for 6 days followed by a subsequent extension cast for 3 days

• Group B: Wore initial resting cast x 2 days, had 15 minutes of preconditioning, wore a continuous extension cast for 3 days, and a subsequent extension cast for 6 days.

• Used torque PROM device to measure PIP extension following removal of each cast

Results

Conclusion•  The increase in PROM of a stiff

joint is directly proportional to the length of time the joint is held at its end range, or TERT

• TERT principle should apply to most synovial joints, not just the PIP

DEMPSEY ET AL. 2011

Retrospective study

• 36 patients (12 low irritability, 24 moderate to high irritability) with frozen shoulder

• Compared ROM, subjective outcomes, and prevalence of re-operation after treatment with the TERT maximizing protocol

TERT maximizing protocol:

• No corticosteroid injections

• Continued outpatient PT and use of NSAID's

• Home use of mechanical therapy device (ERMI shoulder flexionater)

• Six 10-minute bouts of end range stretching per day

• Intensity that was uncomfortable but beneath the pain threshold

DEMPSEY ET AL. 2011

• All patients were initially treated with a customized PT program specific to his/her pathology or surgical procedure

• Patients who failed at least 6 weeks of supervised PT with 3 sessions per week were then treated with the TERT maximizing protocol

Results

• ASES, pain, and activity of living scores all significantly improved

• One subject had re-operation

GASPAR ET AL. 2009

• 62 patients diagnosed with Stage II Adhesive Capsulitis

• 4 intervention categories:

1. Control group – only treated with corticosteroid

2. Physical Therapy with standardized protocols 2x/wk

3. Shoulder Dynasplint system exclusively (60 min/day)

4. Combined Treatment with Shoulder Dynasplint and standardized physical therapy 2x/wk

• Duration: 90 days for all groups

• Outcome Measure: Change in active ER

• Results: Significant improvement found for all groups; Combined Treatment group was the most effective (Mean of 29.8º of change)

Results

TERT CLINICAL APPLICATIONPatient History

• S/P right arthroscopic rotator cuff repair and SAD on 8/23/13

• Pt was undergoing OT for rehab.

• Mid course, pt was lifting a rear hatch on car and felt significant pain.

• Progress with therapy decreased significantly

• Right shoulder arthroscopic adhesion release and manipulation on 3/28/14

• Physical therapy began on 3/28/14

• Limitations = No ER past 40º with arm at side and isometric strengthening exercises only

Plan of care

• Aggressive PT daily x 3 weeks

• Patient education

• UBE x 12 minutes

• Manual therapy for inferior and posterior capsule x 8 minutes

• Manual end range stretching x 10 min

• AAROM, AROM, and passive stretching

• Multiple Angle Isometrics

• Rhythmic Stabilization

• PNF (D2 flexion)

• Cold stretch x 12 minutes

• HEP to be performed daily

• Achieved ~60 minutes of TERT daily

Current PROM180 Flexion

65 ER 70 IR

Initial PROM170 Flexion

40 ERT11 IR

Initial AAROM 158 Flexion

20 ERL3 IR

Current AROM170 Flexion

55 ER 70 IR

Pain6/10

Pain1/10

TERT CLINICAL CONSIDERATIONS

http://getmotion.com/

ERMI Shoulder Flexionater

REFERENCES

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