Saturday, June 12, 2010

Isolated shoulder internal rotation restriction




Isolated shoulder internal rotation restrictions are rare clinical entities for physiotherapist to encounter in OPD set ups.
According to cyriax J in a pan-capsular involvement there is more external rotation restriction than abduction restriction than internal rotation. This restriction pattern is called capsular pattern. So only limitation of internal rotation is attributed to involvement of structures other than capsule i.e. muscles & IDK (labrum problems) etc.

A case in my clinic: A 42 year male reported with lateral arm pain. The patient has cervical spine involvement with Rt side rotation, side bend & back ward bending limited terminally but no ULTT tests ware positive. Both side levator scapulae ware tight.
First 10 sitting ware spend to improve ROM & myofascial work to improve length of elevators of scapula without much avail.

During the second 10 sitting it was found that shoulder IR/hand behind back is limited could reach maximum up to L3. No other shoulder tests are positive. No rotator cuff palpation is positive. During the resisted or active IR the pain was referred o the same spot of the lateral arm. This was little unusual for me. Resisted IR test refers to IDK of shoulder.

I found an opportunity to explore the possibility what is in the literature. So I searched PUBMED with key words (shoulder + Isolated + internal rotation + stiffness). I found 3relevant papers on this issue. Following is the summary

1. Laban et al have described “Occult periarthrosis of the shoulder”. According to this author shoulder internal rotation restriction may lead to complaints of lateral elbow pain similar to complaints of lateral epicondylitis. People from both sexes & age group from 33 to 87 yrs ware found to be affected in this study. The authors have suggested that occult shoulder periarthrosis is interlinked in a pathokinetic chain potentially predisposing to the presenting symptoms of tennis elbow.

2. Lin et al have found a significant relationship between internal rotation and posterior shoulder tightness.

3. Hung et al investigate differences in muscle stiffness between subjects with stiff shoulders and controls, and to determine the correlation between posterior shoulder muscle stiffness and ROM. This study found significant correlations were found between internal rotation and stiffness of 3 muscles i.e. posterior deltoid, infraspinatus, and teres minor. Among these 3 muscles, posterior deltoid muscle stiffness accounted for 51% of the variance in shoulder internal rotation beyond stiffness from the infraspinatus and teres minor muscles.

This study concluded that muscle stiffness is related to shoulder range of motion. It is important to consider the posterior deltoid, infraspinatus, and teres minor muscles in the rehabilitation of patients with restricted internal rotation of the shoulder.

References:
1. Laban MM; Am J Phys Med Rehabil. 2005 Nov;84(11):895-8. (Occult periarthrosis of the shoulder: a possible progenitor of tennis elbow.)
2. Lin JJ et al; Man Ther. 2006 May;11(2):146-52. Epub 2005 Aug 10. (Reliability and validity of shoulder tightness measurement in patients with stiff shoulders.)
3. Hung CJ et al; J Rehabil Med. 2010 Mar;42(3):216-20. (Relationships between posterior shoulder muscle stiffness and rotation in patients with stiff shoulder.)






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