Successful stretching for the stiff shoulder.

A few words at the start:

(1) Here I show a basic approach to stretching for the shoulder that has limited range of motion (i.e. stiffness of the glenohumeral joint). Note that in this post we'll be using the classic illustrations drawn by Steven B. Lippitt.

(2) Often the stiff shoulder has limited motion in multiple directions (shown below for a stiff right shoulder)

Forward Flexion

Abduction

External Rotation

External Rotation in Abduction

Internal Rotation in Abuction

Internal Rotation Up the Back

Cross Body Adduction

(3) Before starting the exercises, the patient should check with the treating physician to make sure they are safe and appropriate. This is especially the case after surgical procedures when tendons, muscles or bone have been repaired. 

(4)  Stretching is most likely to be successful if the joint surfaces of the shoulder are smooth - rather than when there is significant arthritis. However, these exercises may be helpful with mild-moderate arthritis.

(5) Stretching exercises are designed to restore flexibility of the fibrous tissue that surrounds the joint - the capsule - the dark tissue shown surrounding the socket on this view of the inside of the shoulder

(6) These exercises can be effectively carried out by the patient without a therapist (once the physician has given the OK). The exercises shown here require minimal equipment and can be done just about anywhere. Relaxation and patience are essential, however.

(7) For each exercise shown, the stiff arm is helped with the arm on the opposite side so that the muscles around the stiff shoulder can completely relax. The arm is moved to the point where tightness is felt and held there for a minute by the clock during which time a gentle stretch is applied while the muscles remain relaxed. Three sets of the stretches are performed three times a day, striving to make a small, but noticeable gain in the range of motion each time.

(7) Any discomfort from the stretching exercises should subside within 20 minutes. If pain lingers longer than than, the exercises should be performed with less vigor, but still continued regularly.

(8) Here are the basic stretches. I've included links to videos I put together a while back.

A. Assisted Forward Flexion

Video: Forward Elevation: Supine

B. The Forward Lean

Video: Forward Elevation: Forward Lean

C. The Sideways Lean

Video: Abduction stretching - the sideways lean

D. The Sleeper Stretch

Video: Internal Rotation Lying On Your Side 

E. Cross Body Adduction

Video: Cross Body Adduction

F. Up the Back Stretch

Video: Internal Rotation Up Back

Some patients point out that I'm not smiling in the videos.

Perhaps the photo I took last week of a yellow-headed back bird surrounded by bugs will put a smile on your face.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

Anatomic or reverse total shoulder for primary glenohumeral osteoarthritis? What do 10 recent articles say?

There is a growing trend to treat primary glenohumeral osteoarthritis in older individuals with reverse total shoulder arthroplasty (RSA). However, as pointed out by the authors of Limited Preoperative Forward Flexion does not Impact Outcomes Between Anatomic or Reverse Shoulder Arthroplasty for Primary Glenohumeral Arthritis (Sears 2024), "RSA has been shown to generally result in diminished range of motion, particularly internal rotation, compared to anatomic TSA. Additionally, RSA has several unique complications not seen in TSA patients including dislocation, component dissociation, scapular spine fractures and scapular notching."

These authors compared the minimum two year outcomes between TSA and RSA in matched patients under the age of 80 years with primary glenohumeral arthritis and limited preoperative active forward flexion (≤90 degrees). The average preoperative active forward flexion was 68±20 for the TSA and 64±19 for the RSA  groups. The post operative ranges of active flexion were 141±22 and 139±21.

They also examined a subset of matched patients having TSA and RSA with severely limited preoperative forward flexion (≤70 degrees). They found no significant differences in postoperative forward flexion, external rotation, strength, ASES score, VAS, Constant score, SANE score or revision rates between the the TSA and RSA groups. The limited active forward flexion TSA group achieved significantly improved internal rotation compared to the RSA group. 

This article prompted a review of some of the other articles published in 2023 and 2024 that compared TSA and RSA. Eight of these articles addressed particular subsets of patients with glenohumeral arthritis/intact cuff: limited active flexion, limited external rotation range, weak external rotation, and age. The chart below allows the reader to compare the pre and final post operative range of active forward flexion for the shoulders in these eight articles. 

Here is a brief review of the articles.

Comparison between Anatomic Total Shoulder Arthroplasty and Reverse Shoulder Arthroplasty for Older Adults with Osteoarthritis without Rotator Cuff Tears (Kim 2024) compared the clinical outcomes of anatomic TSA and reverse shoulder arthroplasty (RSA) in patients aged over 70 years with primary glenohumeral osteoarthritis without rotator cuff tears. Of the 67 patients included in this study, TSA was performed in 41 patients, and RSA was performed in 26 patients. The two groups had no clinical differences in the patients’ preoperative demographic and radiographic data. At final follow-up, both groups showed improved pain, ROM, and functional outcomes. The TSA group demonstrated significantly better postoperative ASES and Constant-Murley scores than the RSA group. The TSA group showed significantly better postoperative active forward flexion, external rotation and internal rotations than the RSA group. 

In Reverse shoulder arthroplasty with preservation of the rotator cuff for primary glenohumeral osteoarthritis has similar outcomes to anatomic total shoulder arthroplasty and reverse shoulder arthroplasty for cuff arthropathy (Nazzal 2023) TSA was compared to RSA in shoulders with preservation of the rotator cuff. While the TSA patients had more external and internal rotation, there were no significant differences in outcome scores or complication rates.

Patients 75 years or older with primary glenohumeral arthritis and an intact rotator cuff show similar clinical improvement after reverse or anatomic total shoulder arthroplasty (Ardebol 2023) studied patients 75 years of age or older who underwent TSA (n=67) or RSA (n=37) for primary GHOA with an intact rotator cuff with a minimum 2-year follow-up.  The TSA cohort showed significantly greater improvement in external rotation; however both TSA and RSA provided similar clinical outcomes otherwise. 

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative rotational stiffness and an intact rotator cuff: a case control study (Hao 2023) compared stiff patients(ER ≤ 0 degrees) having RSAs to matched stiff patients having TSAs.  Postoperative outcome scores were similar across all matched cohort comparisons. Preoperative limitations in passive ER did not appear to be a limitation to utilizing TSA.

Clinical outcomes of anatomical versus reverse total shoulder arthroplasty in patients with primary osteoarthritis, an intact rotator cuff, and limited forward elevation (Trammel 2023) compared the minimum 2 year outcomes in matched patients with glenohumeral osteoarthritis, an intact rotator cuff, and limited forward elevation (FE ≤ 105°) having TSA (n=344) or RSA (n=163). The outcome scores were significantly better in stiff RSAs compared with stiff TSAs. The complication rate did not significantly differ between stiff TSAs and stiff RSAs, but there was a significantly higher rate of revision surgery in stiff TSAs.

After accounting for confounders, the authors of Similar rates of revision surgery following primary anatomic compared with reverse shoulder arthroplasty in patients aged 70 years or older with glenohumeral osteoarthritis: a cohort study of 3791 patients (Orvets 2023) observed no significant difference in all-cause revision risk for RSA vs. TSA . The most common reason for revision following RTSA was glenoid component loosening. Over half of revisions following TSA were for rotator cuff tear. No difference based on procedure type was observed in the likelihood of 90-day ED visits or 90-day readmissions.

Clinical outcomes of anatomic vs. reverse total shoulder arthroplasty in primary osteoarthritis with preoperative external rotation weakness and an intact rotator cuff: a case-control study (Hones 2024) analyzed the two year minimum outcomes for 333 TSAs and 155 RSAs performed for primary cuff-intact osteoarthritis and having ER weakness (strength <3.3 kilograms (7.2 pounds)). When comparing weak TSA vs.weak RSA, no differences were found in postoperative outcome measures, rate of complications or rate of revision surgery. 

Reverse total shoulder arthroplasty for primary osteoarthritis with restricted preoperative forward elevation demonstrates similar outcomes but faster range of motion recovery compared to anatomic total shoulder arthroplasty (Karimi 2024) sought to determine whether there was a difference in functional outcomes and postoperative range of motion between TSA and RSA in patients with preoperative restricted motion (≤90 degrees of active elevation). There was no difference in outcome scores between RSA (57 patients) and TSA (59 patients). Postoperative active ROM was similar between RSA and TSA cohorts in forward flexion and external rotation. However, internal rotation was less in the RSA group. There was no statistically significant difference in complication rates between cohorts. 

Reverse total shoulder replacement versus anatomical total shoulder replacement for osteoarthritis: population based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England (Valsamis 2024) sought to compare the risk-benefit and costs associated with reverse total shoulder replacement (RSA) and anatomical total shoulder replacement (TSR) in patients having elective primary shoulder replacement for osteoarthritis. RSA had a reduced hazard ratio of revision in the first three years with no clinically important difference in revision-free restricted mean survival time, and a reduced relative risk of reoperations at 12 months. Serious adverse events and prolonged hospital stay risks, change in Oxford Shoulder Score, and modelled mean lifetime costs were similar. Outcomes remained consistent after weighting.  Despite a significant difference in the risk profiles of revision surgery over time, no statistically significant and clinically important differences between RSA and TSA were found in terms of long term revision surgery, serious adverse events, reoperations, prolonged hospital stay, or lifetime healthcare costs.

Comment: These articles show similar outcomes for anatomic and reverse total shoulder arthroplasty in treating patients with primary osteoarthritis with an intact rotator cuff, even for older patients, stiff shoulders and weak shoulders. 

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Arthritis of the shoulder- what patients need to know about the symptoms, diagnosis and treatment of shoulder arthritis

  

What questions do patients have about shoulder joint replacement?

What are the parts of the shoulder and how do they work?

I. What is shoulder arthritis?

II. What are the types of shoulder arthritis?

III. How is shoulder arthritis diagnosed?

IV. What can be done for shoulder arthritis without surgery?

V. What are the important surgical options for treating shoulder arthritis?

VI. What can be done if a shoulder replacement fails to give the desired result?

The Cliff Notes about shoulder arthritis

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Which patients are at risk for stiffness after a ream and run glenohumeral arthroplasty?

Patients with glenohumeral arthritis considering shoulder arthroplasty may wish to avoid the activity limitations and the risk of complications associated with the polyethylene glenoid component used in traditional total shoulder arthroplasty. Avoiding the prosthetic glenoid component eliminates the risk of revision related to glenoid wear, glenoid loosening, and humeral component loosening associated with polyethylene wear. These patients may elect the ream and run glenohumeral arthroplasty (RnR) (see this link).

Some patients experience stiffness after the RnR which, if severe, can lead to repeat procedures such as a manipulation under anesthesia (MUA) or an open surgical revision. The authors of Risk Factors for Stiffness Requiring Intervention After Ream-and-Run Arthroplasty sought to determine risk factors associated with repeat procedures performed for postoperative stiffness after ream and run arthroplasty.

They identified 340 patients who underwent the ream and run arthroplasty in a longitudinally maintained database with a mean follow-up of 2.1 years. Patients who underwent a repeat procedure and the control group of patients who did not undergo a repeat procedure had similar preoperative mean SST scores (4.8 compared with 5.0) and SANE scores (38.8 compared with 41.0). The mean Simple Shoulder Test (SST) scores for all patients significantly improved from 5.0  preoperatively to 10.2 postoperatively. The mean SANE scores improved from 40.6 preoperatively to 80.3 postoperatively. 

Thirty-five patients (10.3%) elected to undergo an MUA. These procedures were performed at a mean of 8.7 months after the index arthroplasty.

Twenty-six patients (7.6%) underwent subsequent open procedures to treat stiffness. Four patients underwent a conversion to an anatomic total shoulder arthroplasty; the remaining 22 patients had soft tissue releases and downsizing of the humeral head component thickness. These procedures were performed at a mean of 20.6 months (range, 0.9 to 71.7 months) after the index arthroplasty. 

At the time of open revision, 69.2% (18 of 26) had ≥2 cultures positive for Cutibacterium.

Younger age, female sex, and lower American Society of Anesthesiologists (ASA) class were significant risk factors for repeat procedures. Patients who underwent a repeat procedure had greater preoperative posterior decentering (10.7% compared with 8.1%) but similar Walch classification and preoperative retroversion. Patients who required a repeat procedure had less forward elevation (125.7° compared with 143.3°) noted by an individual designated physical therapist at the time of hospital discharge after the index surgical procedure. Preoperative diagnosis, BMI, insurance type, employment, opioid use, smoking status, prior procedures on the same shoulder, head thickness, use of an eccentric head, and rotator interval plication were not significantly different between those who required repeat intervention and those who did not.

Patients who underwent a repeat procedure had lower mean scores at 2 years for the SST (8.2  compared with 10.6) and SANE (68.4 compared with 82.7).  The mean SST scores of patients undergoing MUA (6.2) were significantly lower  than those of patients undergoing open revision (9.7).










Multivariate analysis found younger age, ASA class 1 compared with class 3, and less passive forward elevation at discharge to be independent risk factors for repeat procedures.

Comment: While the overall outcome for these 340 patients were good - the SST improved from 5 out of 12 preopeartively to 10.2 out of 12 at two years after surgery - there are lessons to be learned from this study.

Achieving immediate range of motion and maintaining it throughout the rehabilitation period is essential to the success of the ream and run procedure. Less forward elevation at the time of discharge from the hospital after a ream and run was an independent risk factor for a repeat procedure. This finding demonstrates that the finding of less than 130 degrees of flexion in the immediate postoperative period can identify patients who may benefit from a more aggressive early rehabilitation protocol. 

Younger age and better health were independent risk factors for repeat procedures to address stiffness. Younger patients may have higher expectations and, therefore, a lower threshold for a second procedure to address stiffness. It is also known that stiffness can be caused by a low grade periprosthetic infection from Cutibaterium. Young, healthy patients selecting the ream and run are at greater risk for these infections, which typically present as pain and stiffness in absence of the usual signs of periprosthetic joint infection from other bacteria (elevated serum markers, fever, chills, joint swelling, and a draining sinus). In Factors predictive of Cutibacterium periprosthetic shoulder infections: a retrospective study of 342 prosthetic revisions) the authors found that patients with definite Cutibacterium periprosthetic infections were younger (59 ± 10 vs. 64 ± 12, P < .001) and had lower American Society of Anesthesiologists scores (1.9 ± 0.7 vs. 2.3 ± 0.7, P < .001). In Risk Factors for Stiffness Requiring Intervention After Ream-and-Run Arthroplasty, over two-thirds (69.2%) of the open revisions for stiffness had multiple positive intraoperative cultures for Cutibacterium.  

Preoperative posterior decentering was significantly greater in the group that required repeat intervention. At surgery, posterior decentering may addressed by increasing the thickness or diameter of the prosthetic head, use of an anteriorly eccentric humeral head, and performance of rotator interval plication. These modifications that are carried out to help center the humeral head on the glenoid may contribute to postoperative stiffness,

Patients at risk for postoperartive stiffness may benefit from greater soft-tissue releases, smaller humeral head components, more aggressive rehabilitation, and close monitoring of their range of motion after the surgical procedure. Furthermore, surgeons should be alert to the possibility of Cutibacterium periprosthetic infection in shoulders developing stiffness after the ream and run procedure.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Should an anatomic or reverse total shoulder be used to treat stiff shoulders?

Many arthritic shoulders are not only painful but stiff.

Documenting the preoperative loss of passive range of motion (stiffness) in different directions indicates the type and severity of the limitation of motion (see these drawings by Steve Lippitt).


Flexion



Abduction





External rotation with the arm at the side




External rotation with the arm abducted




Internal rotation with the arm abducted



Reach up the back (the posterior segment that can be reached by the thumb)

and cross body adduction (the distance between the antecubital fossa and the contralateral acromion note the two-headed arrows).




Stiffness of the arthritic shoulder can be caused by muscle and capsular contracture,



osteophytes blocking motion


irregular joint surfaces,



bony deformities



prior surgical procedures


and scarring in the humeroscapular motion interface



It is often worthwhile to offer the patient with a stiff arthritic shoulder a trial of gentle stretching exercises for two reasons: (1) it may substantially improve their comfort and function and (2) it familiarizes them with the exercises that will be part of their postoperative recovery if they proceed with surgery. See Essential Shoulder Exercises.

Our approach to anatomic shoulder arthroplasty is shown here.

Surgical management of stiffness begins with the approach, including a 360 degree release of the subscapularis, which is often tethered





and release of the contracted capsule while protecting the axillary nerve (yellow)




With the trial components in place, the 40, 50, 60 rules can be useful targets for achieving a flexible and stable arthroplasty:

40 degrees of external rotation with the subscapularis approximated to the lesser tuberosity



50% translation on posteriorly directed loading of the proximal humerus



60 degrees of internal rotation with the arm in 90 degrees of abduction




The tightness/laxity of the shoulder can be adjusted by selecting the thickness of the humeral component that provides the desired mobility and stability.



Important causes of stiffness after an anatomic shoulder arthroplasty include

Overstuffing - too much component volume for the space available in the joint (similar to the scene in Alice in Wonderland when Alice eats a cake that makes her grow excessively).





Overstuffing can result from an inadequate humeral neck cut



from an excessively large humeral component


from a too thick glenoid component




from failure to seat the humeral component fully


from inserting the component in varus



from failure resect osteophytes at Pooh Corner



posteriorly, resulting in open booking when the arm is externally rotated



or globally



The authors of Clinical Outcomes of Anatomic Versus Reverse Total Shoulder Arthroplasty in Primary Osteoarthritis with Preoperative Rotational Stiffness and an Intact Rotator Cuff: A Case Control Study compared clinical outcomes of anatomic (aTSA) and reverse (rTSA) total shoulders performed in stiff versus non-stiff shoulders with rotator cuff intact (RCI) glenohumeral osteoarthritis (GHOA). The indications for choosing an aTSA or a rTSA are not specified. The techniques for addressing shoulder stiffness were not reported.

They defined preoperative stiffness as external rotation ≤0 degrees. They conducted a retrospective review of 1608 aTSAs and 600 rTSAs performed for RCI GHOA.

They found that patients with limited preoperative ER and RCI GHOA had lower postoperative ROM compared with non-stiff shoulders when treated with either aTSA or rTSA. Stiff shoulders treated with aTSA had better postoperative IR and ER compared to a matched cohort of stiff shoulders treated with rTSA. All groups, regardless of preoperative stiffness, had similar postoperative clinical outcome scores. They concluded that preoperative limitation in passive ER does not appear to be a limitation to utilizing aTSA in patients with RCI GHOA.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).