Post-Operative Shoulder Pain and Limited Range of Motion
A 61-year-old man presents 8 weeks after right rotator cuff repair (supraspinatus) with persistent shoulder pain and stiffness. He reports pain at night and difficulty reaching overhead. His surgeon has cleared him for physical therapy but not for aggressive stretching. On exam: active forward flexion 90 degrees, passive forward flexion 110 degrees, external rotation 20 degrees, and internal rotation to the buttock. There is tenderness over the anterior shoulder and deltoid. Strength is 4/5 in the supraspinatus. He has a history of adhesive capsulitis in the contralateral shoulder. He asks whether OMT can "loosen it up."
1. What is your differential for his limited motion, and how do the surgical constraints shape your assessment?
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Differential:
- Post-operative stiffness / early adhesive capsulitis - limited passive motion (external rotation 20 degrees), night pain, and a history of contralateral frozen shoulder make this likely.
- Re-tear or incomplete healing - would present with weakness and pain; 4/5 supraspinatus strength is concerning but not definitive.
- Subacromial impingement / bursitis - pain with overhead motion, tenderness over the anterior shoulder.
- Cervical radiculopathy referral - screen with Spurling's and neurologic exam (not described; should be performed).
Surgical constraints:
- The repair is 8 weeks out; the tendon is still healing. Aggressive stretching or thrust manipulation could jeopardize the repair.
- The surgeon's clearance is for PT, not for forceful mobilization; clarify the specific restrictions.
- Passive range of motion is the key differentiator: if passive motion is also limited (as here), stiffness/capsulitis is more likely than pure weakness.
Teaching point: After rotator cuff repair, the timeline and surgeon's restrictions dictate technique selection; the exam must distinguish stiffness from re-tear.
2. What OMT techniques are appropriate, and what would make you stop or refer?
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Appropriate techniques (gentle, within surgical restrictions):
- Soft-tissue/myo-fascial release to the pectoralis, deltoid, and posterior cuff.
- Muscle energy for gentle glenohumeral and scapulothoracic mobility.
- Scapular mobilization and thoracic spine OMT to improve scapulothoracic mechanics.
- Counterstrain for tender points.
- Avoid high-velocity thrust to the glenohumeral joint and aggressive end-range stretching.
Stop/refer if:
- Sudden loss of strength or a new pop suggests re-tear.
- Increasing pain or night pain that worsens despite gentle care.
- Failure to progress beyond expected milestones.
- Any neurologic deficit.
Coordinate with the surgeon and physical therapist; document the restrictions and the techniques used.
Teaching point: OMT after surgery is adjunctive and must respect tissue healing timelines; the practical exam tests whether you can select safe techniques and recognize when to refer.