The March-April 2010 issue of the Journal of Sports Health has several insteresting studies. This particular study compared the effectiveness of stretching vs. stretching with joint mobilization for posterior shoulder tightness measured by internal rotation loss.
Now for starters, the hypothesis was interesting. Going into the study, the researchers hypthesized:
“Shoulder internal rotation range of motion will not change with either of 2 interventions: cross-body stretch alone and cross-body stretch plus posterior capsule joint mobilization”
So going into the study, the researchers were not convinced either of these two methods would effectively produce a change in internal rotation range of motion. As the pursuit of evidence based medicine continues, studies like this that prove to provide evidence with which to base our treatment decisions is important.
A second point of interest was the underlying premise that the posterior capsule is responsible for the loss of internal rotation. There is growing belief that this is not necessarily the case. Can this paper-paper thin structure be responsible for interal rotation ROM loss? The authors did not and I won’t answer this question but an interesting side note nonetheless.
The study measured 39 asymptomatic individuals who had a minimum of a 10 degree loss between the “treated” shoulder and the “control” shoulder. Twenty shoulders were treated with stretching only and 19 shoulders were treated wtih stretching + joint mobilization.
The stretch that was chosen for both groups was the cross-body stretch. Traditionally, there are probably three common self stretches that are chosen to address internal rotation loss. These stretches are: the towel stretch, the sleeper stretch, and the cross body stretch. A study by McClure et al compared the cross body stretch and the sleeper stretch and research determined that the cross body stretch was superior. Hence, this stretch was chosen for the purposes of this study.
As far as the study was concerned, the stretch in both groups was done on their own at 5 sets x 30 seconds each. This was done a minimum of 3-4 times a week for 4 weeks. This stretch was done in a sitting or standing position without concern for stabalizing the scapula.
As far as the joint mobilization, posterior capsule mobilizations (grade III and IV) were performed for a total of 10 minutes at a minimum of 2 sessions per week for 4 weeks. Again, the stretching and joint mobilization groups included both interventions while the stretching only group used the stretching only strategy.
Overall, both the stretching and stretching plus joint mobilization groups resulted in increased internal rotation range of motion - both at the end of the 4 week period and at 4 weeks post-intervention. The conclusion of the study was as follows:
“The cross-arm stretch with joint mobilization and the cross-arm stretch along can significantly increase shoulder internal rotation following 4 weeks of intervention in a group of asymptomatic college age students.”
One further point about the study results that stuck out: the stretching plus joint mobilization resulted in greater gains at 4 weeks than the stretching only group but the results at 4 weeks post appear to be pretty comparable between teh ROM gains.
Now the authors did note some limitations with the study. The limitations noted were: asymptomatic participants, a convenience sample, measurement error, and a 10 degree difference in internal rotation between shoulders. Probably the biggest of which, in my mind, is the fact that the subjects in this study were asymptomatic – they simply had bilateral motion differences between shoulders for internal rotation. Whether or not this particular strategy would be effective for someone presenting with internal rotation loss while symptomatic remains to be seen.
However this does give us a starting point to begin our treatment planning.
Number one, as an injury prevention strategy for those who have ROM limits but are asymptomatic, a 4 week stretching program using the cross body stretch is probably a good starting strategy.
Regarding symptomatic patients with loss of internal rotation, this may be a part of the treatment strategy package. As we plan our strategy, this study gives us some considerations.
If some already presents with IR deficiency accompanied by pain, a towel stretch behind the back probably is not going to be very comfortable. It is very common that this motion is painful for patients to begin with. Having them to push through pain to increase ROM in this method makes little sense. So if the towel stretch is currently a common staple of your treatment protocol in these particular cases, there very well could be a better strategy.
The sleeper streth is another common method of stretching. This stretch certainly has it’s place. To restore range of motion in an injured shoulder – may or may not be effective. Again, whether or not the stretch causes pain is a chief consideration. Some patients cannot tolerate this stretch real well early on in the rehabilitation process.
The cross arm stretch, studied in this particular research piece, is shown to be effective in asymptomatic individuals. Again, when applying with symptomatic individuals, working within a pain-free is very important.
The other consideration, especially with this particular stretch, is stabalization of the scapula. Again, working within a pain-free range, stabalizing the scapula is a better technique than simply the cross body stretch while sitting or standing.
To stabalize, one can lie on their side and use body weight to help stabalize the scapula. (Eric Cressey demonstrates this stretch on his blog here.)For the clinician-assisted stretch, this stretch can be done with the patient supine and you can use your under hand to stabalize and provide medial pressure to the scapula while using the opposite hand to horizontally adduct the arm and provide that cross body stretch. (Mike Reinold demonstrates this technique in one of his posts - scroll to the bottom of the post). To enhance the stretch, you can take the arm being stretched straight across or add a little internal rotation component as well. Again, all within pain-free limits.
In the symptomatic patient, if these stretching techniques cannot be done without pain, then some gentle joint mobilizations may be a places to start.
So while this study admittedly doesn’t answer all of our questions, particularly in relation to our symptomatic patients, it does gives us a frame of reference we can start with when addressing the issue of internal rotation loss of motion.
What are your thoughts? What strategies have you effectively employed to restore internal rotation ROM?
