Joint Mobilization for Shoulder Stiffness
Direct Recommendation
For adults with shoulder stiffness (limited elevation and rotation), use high-grade mobilization techniques (Grades III-IV) performed at end-range positions of the glenohumeral joint, combined with stretching exercises focusing on external rotation and abduction. 1, 2
Evidence-Based Mobilization Protocol
Primary Technique Selection
High-grade mobilization techniques (HGMT) are superior to low-grade techniques for improving glenohumeral joint mobility and reducing disability in adhesive capsulitis, with statistically significant improvements in passive external rotation, abduction, and shoulder disability scores over 12 months. 1
The Maitland technique (Grades III-IV mobilization) is the most evidence-supported approach among various mobilization methods, showing consistent improvement in both pain scores and range of motion. 3
Translational mobilizations should emphasize posterior glides specifically to restore external rotation, which is typically the most limited movement in shoulder stiffness. 3
Specific Technical Parameters
Position for Mobilization
Perform inferior mobilizations in neutral position (arm at side) rather than the traditional open-packed position (55° abduction, 30° horizontal adduction), as this produces greater humeral movement (1.8mm, 3.8mm, 4.5mm for grades I, II, III respectively) despite requiring higher forces. 4
The neutral position generates superior translational movement compared to 90° abduction position, which produces minimal movement (1.0mm, 2.2mm, 2.3mm for grades I, II, III). 4
Treatment Frequency and Duration
Implement mobilization 2 times per week for up to 12 weeks (maximum 24 sessions) as this dosage has demonstrated effectiveness in randomized controlled trials. 1
Flexibility exercises should be performed ≥2-3 days per week, with daily exercise producing the greatest gains in joint range of motion. 5
Essential Complementary Interventions
Range of Motion Exercises
Focus specifically on external rotation and abduction movements through both passive and active-assisted exercises to prevent progression to frozen shoulder. 2
Hold static stretches for 30-60 seconds in older adults, as this duration confers greater benefit than shorter holds. 5
Stretch to the point of tightness or slight discomfort, not beyond, to avoid tissue damage. 5
Critical Avoidance
- Never use overhead pulley exercises, as they encourage uncontrolled abduction and can worsen shoulder pathology through improper mechanics. 5, 2
Important Clinical Considerations
When Mobilization May Not Help
Recent systematic review evidence shows that glenohumeral joint mobilization provides no significant clinical benefit when added to exercise programs for rotator cuff disorders, with very low to high quality evidence showing mean differences of only -3.42° for flexion and 0.65° for external rotation at 4-6 weeks. 6
This suggests mobilization is most appropriate for primary adhesive capsulitis/stiffness rather than rotator cuff pathology. 3, 1
Progression Strategy
Begin with Grade III mobilizations (large amplitude movements into tissue resistance) and progress to Grade IV (small amplitude movements at end-range) as tolerance improves. 1
Gradual progression of greater resistance and/or more repetitions is recommended, though optimal progression methods for neuromotor exercises remain undefined. 5
Adjunctive Pain Management
Consider subacromial corticosteroid injections if inflammatory/structural shoulder pain is present with verified ultrasonographic findings, though these provide only short-term relief. 2, 7
Ice, heat, and soft tissue massage can provide symptomatic relief during the mobilization treatment course. 2
Common Pitfalls to Avoid
Do not use low-grade mobilizations (Grades I-II) as primary treatment for stiffness, as they produce significantly less improvement in mobility and disability compared to high-grade techniques. 1
Avoid aggressive or forceful manipulation without proper technique, as improper handling of the complex shoulder joint can cause more harm than good. 5
Do not delay treatment, as prolonged stiffness can lead to secondary complications including depression, insomnia, and reduced quality of life. 2
Ensure proper positioning during mobilization - the traditional "open-packed position" may not be optimal for inferior glides despite being commonly recommended. 4