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

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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).

How stretch the posterior shoulder capsule

Effective stretching positions for the posterior shoulder capsule as determined by shear wave elastography

These authors sought to identify the stretching positions that specifically applied the greatest passive tension on the posterior shoulder capsule by evaluating the elastic characteristics of posterior capsules and muscles in various stretching positions using ultrasound shear wave elastography in 9 fresh-frozen cadaver shoulders without osteoarthritis or rotator cuff tears. 

All posterior shoulder tissues were preserved intact. Shear moduli of the middle and inferior posterior shoulder capsule and the posterior shoulder muscles were evaluated in combinations of glenohumeral

elevation planes and angles (frontal, sagittal, scapular; –30, 0, 30, 60, respectively). A 4-Nm torque for shoulder internal rotation or horizontal adduction was applied in each position. 

They found that the middle posterior capsule was most effectively stretch by internal rotation at 30 of elevation in the scapular plane and cross body adduction at 60 of elevation. The inferior posterior shoulder capsule was most effectively stretched by internal rotation at 30 of flexion.

Comment: Posterior capsular tightness is a common finding on careful evaluation of the painful shoulder, although it is often overlooked by the casual observer. It can be noted by (a) limited cross body adduction, (b) limited internal rotation with the arm abducted, and (c) by limited reach up the back. As found in cadavers by the authors, we have found that the posterior capsule can be effectively stretched by cross body adduction (see this link) and the sleeper stretch (see this link). 

How you can support research in shoulder surgery Click on this link.

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).

(Zen and) The Art of Rehabilitating a Shoulder - Part one, stretching

Writing this reminds us a bit of this book, which may be known to some of you more senior readers. In it, the author explores the meaning and concept of "quality" a phenomenon that exists between the subject and the object. You'll have to decide whether you prefer the "classical" or the "romantic" approaches that he describes. Here is our "classical" approach to the rehabilitation of most of our total shoulders, ream and runs, cuff tear arthropathy arthroplasties, and hemiarthroplasties.

This rehab program is based on the tenet that the "patient is the method": the patient is the "subject" and the shoulder is the "object". The success of the program will depend on the patient's dedication to it and on the patient's willingness to experiment a bit with the art to see how many repetitions, how much resistance, and what pace of progression works best.

We will assume that the goal is excellent function and that there are no special considerations based on the findings at surgery or on the specifics of the procedure performed. We do not use this approach for reverse total shoulders and, on occasion, need to modify it for anatomic total shoulders or ream and run procedures. Don't even think about launching on this program after an operation without reviewing it in detail with the surgeon.

 We use several "rules of thumb" for our stretching exercises - best done five times a day and best done with a one minute hold at a point just beyond the comfortable range of motion using the opposite arm for power while the rehabilitating arm is relaxed. The goal is to gain a few degrees each day, starting the evening after surgery.


Stretching in flexion. Here's a goal for six weeks after a usual anatomic shoulder replacement

Check progress by lying on a flat surface and having someone take a photo from the side so that you can measure the angle with a protractor

 or goniometer.

There are three exercises that are useful in getting this range of flexion after a joint replacement (demonstrated by one of our ream and run rock stars).

(1) Pulley (often the easiest)(see this youtube)

(2) Supine stretch (see this youtube)

(3) Forward lean (usually the most effective)(see this youtube)

In most cases it is also important to stretch the posterior capsule.

There are four exercises that are helpful in achieving this goal

(4) Cross body adduction (see this youtube)

(5) Reaching up the back (see this youtube)

(6) Sleeper stretch (see this youtube)

(7) Sideways lean (see this youtube)

We specifically avoid stretching in external rotation for the first 3 months after a shoulder joint replacement for reasons explained in this link. In situation where external rotation is deemed appropriate, it can be performed as shown here

(8) External rotation stretch AVOID For three months after a shoulder arthroplasty!

In our next post, we'll talk some about strengthening.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Shoulder stretching and your electric toothbrush

Some of our patients have pointed out that they do 3 minutes of electric toothbrush several times a day and combine this with their shoulder stretching, which is best done with a 3 minute hold.

This is a two for one approach that keeps the mouth and the shoulder happy.

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Successful stretching

Shoulders tend to get stiff - after an injury, after surgery or for no apparent reason. Gentle, frequent stretching is very often successful in reducing stiffness. The key to a successful stretching program is relaxing while holding the stretch for a full two minutes (by the clock) and repeating the stretches every few hours during the day. The stretching programs we favor are those that require no equipment and that can be done anywhere.

These are shown here:

    A. Forward Elevation: Supine
    B. Forward Elevation: Forward Lean

    C. Forward Elevation: Over Door Pulley
    D. External Rotation

    E. Cross Body Adduction

    F. Internal Rotation Up Back 

    G. Internal Rotation Lying On Your Side 

Of these the ones we've found most successful in improving elevation of the arm are the forward lean (B in the list above) and the sleeper stretch (G in the list above).

How you can support research in shoulder surgery Click on this link.

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).

Swimmer's stretch

For certain sports, having a completely full range of flexion is important. We're impressed with our patients' ability to come up with variations on the flexion stretch.
Here's a photo of one of our patients from Hawaii, a triathlete, who has found a novel twist on the flexion stretch. This method has the advantage of allowing him to relax and apply gentle pressure over ten minutes. The picture speaks for itself.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

See from which cities our patients come.

See the countries from which our readers come on this post.

Stiff shoulder, painful shoulder, frozen shoulder, shoulder arthritis

Shoulder stiffness means that the shoulder is not able to move through its normal range of motion.  There are many causes of shoulder stiffness, including shoulder arthritis and frozen shoulder.  These two diagnoses can be distinguished by obtaining standardized shoulder x-rays which should be normal in a frozen shoulder but show a narrowed joint space in arthritis.

In deciding if a shoulder is stiff, it is helpful to compare its ability to perform several motions in comparison to the opposite normal shoulder. 

Here are the most important motions to compare:

      I. Internal and external rotation with the arm at the side (measured in terms of degrees from vertical)

    II. Forward elevation (measured in terms of degrees from the horizontal)

   III. Internal rotation up the back (measured in terms of the part of the back that can be reached with the thumb).

IV. Cross-body reach (measured as the distance from the elbow to the opposite shoulder).

V. Internal rotation with the arm out to the side (measured as degrees from the vertical).

The last three of these are often the motions limited early on in the process, so checking them may be revealing.

If your shoulder is stiff, check with your doctor to see how it may be best managed. 

We have found that whether the stiffness is due to arthritis or to a frozen shoulder, gentle stretching exercises are often helpful. 

Here are some other posts on stretching

Forward lean

How to stretch and how not to stretch

Shoulder exercises

Exercise videos

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

See from which cities our patients come.

See the countries from which our readers come on this post.

Ream and Run, Total shoulder, Reverse total shoulder, CTA arthroplasty

There are a variety of shoulder joint replacement procedures for the management of the different types of shoulder arthritis, including degenerative joint disease (osteoarthritis) and chondrolysis.
For individuals with rheumatoid arthritis, there may be some special concerns regarding medication around the time of surgery.
These include
A total shoulder for most individuals with arthritis and a functioning rotator cuff. A video is shown here.
A ream and run for individuals with arthritis who desire high levels of physical activity, including impact to the shoulder. A bit about the rational and technique is shown here, here and here. And some details of the technique are shown here.
A CTA arthroplasty for individuals with arthritis and rotator cuff deficiency, but with good shoulder stability and the ability to actively raise the arm. A two year result is shown here.
and
A reverse total shoulder for individuals with arthritis and rotator cuff deficiency and either instability or the inability to raise the arm by itself. A bit more about this procedure can be seen here and here

The rehabilitation after any shoulder replacement needs to be specified by the surgeon. Not infrequently modifications need to be made based on the details of the findings at surgery and the specifics of surgery. For total shoulders and for the ream and run we often prescribe the exercises shown in the following links
Post 1
Post 2
Post 3
Post 4

As well as this series of videos
Supine stretch
Pulley
One month
6 weeks
7 weeks
8 weeks
10 weeks
12 weeks

Some other exercises that can be considered if advised by the surgeon are shown here.

The recovery after shoulder replacement can be documented by following the simple shoulder test scores as shown here

Some patients have generously provided a diary of their recovery after the ream and run,  as shown in these links
Post A
Post B
Post C
and if you like drumming
Post D
or chopping wood
Post E
or raquetball
Post F
or kayaking
Post G
or badminton and weights
Post H
or getting 'Grandpa' back up on his slalom ski that had been put away for 7 years
Post I
or violin
Post J


After all shoulder joint replacements, we recommend antibiotics before dental and other procedures.

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Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

See the countries from which our readers come on this post.