The effectiveness of trigger point treatment in rotator cuff pathology: A randomized controlled double-blind study

Abstract

BACKGROUND:

Studies have emphasized the importance of the presence of myofascial trigger points (MTrPs) in patients with rotator cuff pathologies and the high frequency of MTrPs in rotator cuff muscles.

OBJECTIVE:

Evaluate the effectiveness of the treatment of active MTrPs in patients with rotator cuff pathologies.

METHODS:

Fifty-three patients with rotator cuff tear were randomized into two groups. All patients received the same standard conservative treatment twice a week for 6 weeks. Patients in Group 1 additionally received ischemic compression (IC) of MTrPs. Pain, range of motion (ROM), function, and anxiety and depression were assessed. MTrPs in rotator cuff muscles were assessed manually, and the number of MTrPs on the shoulder complex was counted.

RESULTS:

There were no significant differences between the groups in terms of changes in resting/activity/night pain, ROM, function, or anxiety and depression ( $p>$ 0.05). Pain scores improved only in Group 1. However, the total number of MTrPs was significantly decreased in Group 1 ( $p=$ 0.001).

CONCLUSION:

A six-week course of IC helps treat active MTrPs. A standard conservative treatment program reduced pain and increased function; the addition of MTrP treatment did not improve clinical outcomes in patients with rotator cuff pathologies.

Keywords

Shoulder pain trigger points range of motion rehabilitation

1. Introduction

Rotator cuff pathologies are a prevalent clinical issue caused by many factors such as age-related degenerative changes and trauma [1]. Symptoms of rotator cuff tear mostly include pain, limited range of motion (ROM), and dysfunction [2]. Rotator cuff tears may be partial or full thickness. Partial rotator cuff tears may be associated with shoulder pain and shoulder weakness when the hand is raised above shoulder height or reached behind the back of the body. On the other hand, full-thickness rotator cuff tears may be associated with intense shoulder pain and an inability to lift the arm away from the body [3].

Myofascial pain syndrome, which can be related to rotator cuff problems, is a common condition that, by definition, results from trigger points [4]. Myofascial trigger points (MTrPs) are specific tender spots that produce symptoms known as myofascial pain [5]. MTrPs have been classified as active and latent trigger points by Simons et al. [6]. An active MTrP is always tender, avoids full lengthening of the muscle, weakens the muscle, and results in patient-recognized pain upon compression [6]. Studies have emphasized the presence of MTrPs in patients with rotator cuff pathologies and the high frequency of MTrPs in rotator cuff muscles [7, 8]. Suh et al. [9] reported that patients with rotator cuff pathologies are more prone to developing MTrPs than shoulder without rotator cuff pathologies.

The optimal treatment for symptomatic, non-traumatic rotator cuff tear is unknown [10]. Standard conservative treatments of rotator cuff tears are ROM exercises, stretching, strengthening, and mobilization; treatment options for MTrPs include ischemic compression (IC), manual techniques, transverse friction massage, spray and stretch, post-isometric relaxation, stretching, trigger point needling, and postural correction [5, 11]. However, no studies have investigated the effectiveness of trigger point treatment in addition to rotator cuff treatment [5]. We hypothesized that the treatment of MTrPs would be more effective at reducing pain as well as increasing function and ROM in patients with rotator cuff tears. The aim of this study was to investigate the effectiveness of the treatment of active MTrPs in patients with rotator cuff tears.

2. Methods

2.1 Study design

The clinical study was designed as a prospective, randomized, double-blind study. The research protocol was devised according to the CONSORT guidelines (see CONSORT checklist) and was confirmed by the Human Research Ethics Committee of Bakirkoy Dr. Sadi Konuk Training and Research Hospital (IRB: 2015-281). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was provided by all patients prior to their enrollment.

2.2 Participants

The participants were recruited from Bakirkoy Dr. Sadi Konuk Training and Research Hospital and treated at the clinical laboratory of the Physiotherapy Department of Istanbul University from May 2016 through September 2017. Patients with ages between 30 and 60 years were included if they had partial rotator cuff tears, MRI demonstration of a rotator cuff tear, positive results for a Hawkins-Kennedy test [12] or positive results for an Empty Can test [13], at least three trigger points in their shoulder complex, symptoms persisting for at least 3 months, and no radiographic signs of glenoid or bone fracture. Patients were excluded if they had a shoulder instability, an insufficient response to non-operative management (including local corticosteroid injection, non-steroidal anti-isnflammatory drugs, rest, and physiotherapy). Patients were also excluded if they had inflammatory joint diseases, rheumatic diseases, frozen shoulders, massive rotator cuff tears, osteoarthritis of the humeral head, thoracic outlet syndrome, prior surgery on the affected shoulder, or were unable to complete the questionnaires due to language problems or cognitive disorders.

2.3 Randomization and blinding

The participants were randomly assigned to one of two intervention groups (ratio: 1:1) using “Research Randomizer”, an online randomization web service (https://www.randomizer.org). Simple randomization procedures (computer-generated numbers) were utilized, and sequentially numbered index cards containing the random assignments were prepared by an investigator with no clinical involvement in the research. The index cards were folded and placed into sealed envelopes. Two independent physiotherapists performing the interventions then opened each envelope and divided the participants into the groups according to the selected index card. Same physiotherapist carried out all of the interventions of the one patient during 12 sessions in the research clinic of the university. Another physiotherapist, blinded to the allocation of the participants, conducted the evaluations before and after 6 weeks of treatment (assessor-blinded). The participants remained blinded as to which group they were in.

2.4 Outcome measures

All outcome measures were applied in the stated order in all patients. The Visual Analogue Scale (VAS); each patient was asked about pain during periods of rest (VAS-rest), during activities of daily living (VAS-activity), and at night during sleeping (VAS-night) [14]. Pain-free active and passive shoulder forward flexion, abduction, and scapular plane external-internal rotation ROM were evaluated using a standard goniometer [14, 15]. Function was assessed by the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire [16] and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) Form [16, 17, 18]. Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale (HADS), which was divided into Anxiety (HAD-A) and Depression (HAD-D) subscales [19, 20].

Active MTrPs were examined in the scalene, levator scapulae, upper trapezius, supraspinatus, infraspinatus, teres major, latissimus dorsi, anterior-posterior deltoid, subscapularis, pectoralis major-minor, and biceps brachii muscles. Active MTrPs diagnosis was done in agreement with the criteria described by Simons et al. [6].

The VAS, ROM, DASH, ASES, and HAD scores, as well as all of the shoulder muscles with active MTrPs, were assessed at baseline (first assessment) and after a six-week treatment (second assessment).

2.5 Interventions

The patients were randomly divided into two groups. Patients in Group 1 received treatment of active MTrPs in addition to standard conservative treatment program; patients in Group 2 received only the standard conservative treatment program. All patients received the same standardized conservative treatment, ergonomic recommends, and instructions to assume and maintain good posture. The conservative treatment was applied twice a week for 6 weeks (12 sessions) for both groups, and it was followed by cold application to the shoulder complex for 15 minutes. Patients in Group 1, in addition, received manual IC of active MTrPs. The outline of the rehabilitation program is provided in the Appendix. Patients were asked to perform gentle static stretching and relaxation exercises at home two times per day.

The application of IC is described by Simons et al. [6]. This technique involves stretching a relaxed muscle close to the point of discomfort. Initially, tolerably painful (discomfort intensity level 7–8 out of 10) and sustained pressure was directly applied on the active MTrP using a thumb. The treatment is not helpful if the patient tightens up his or her muscles and consequently protects the active MTrPs from pressure. The compression was continued for 90 seconds. The aim of this compression is to intentionally increase the blockage of the blood of an area in order to provide a resurgence of blood flow, which helps the affected tissue heal after the pressure is released [6]. All of the participants were instructed not to take any analgesic or anti-inflammatory medications during the study.

2.6 Sample size determination

The sample size and power analysis of the study were determined using PS power analysis. All of the patients were analyzed using intention-to-treat analyses. Calculations were performed at a 95% confidence interval and a power level of 95%. The DASH questionnaire exhibited a standard deviation (SD) of 13 points and a minimal clinically important difference of 15 points [21]. These parameters constituted at least 12 samples per group. When a conservative drop rate was added, 53 volunteers were included in the study.

2.7 Data analysis

Data analyses were performed using the SPSS version 20.0 statistical software package (SPSS Inc., Chicago, IL). Statistical significance was set for all testing at $P<$ 0.05. An independent samples $t$ -test and a chi-squared test were used to assess the baseline demographic data between the treatment groups for continuous and categorical data, respectively. The VAS, ROM, DASH, ASES, and HAD scores were analyzed using a 2-by-2 mixed model analysis of variance (ANOVA) with treatment group (Groups 1 and 2) as the between-subject factor and time (before and after treatment) as the within-subject factor. Intention-to-treat analysis was conducted with missing data, which were computed using regression equations. Pre- and post-treatment values within the groups were compared using a paired sample $t$ -test.

Additionally, treatment effects were directly compared with reported minimum clinically important differences (MCIDs) in the literature. An established MCID for the VAS, DASH, and ASES has been suggested to be 2.14 cm, 10.2, and 6.4 points, respectively [22, 23, 24]. Effect sizes (ESs) were determined by calculating the differences in the means of the baseline and the follow-up data divided by the SD at the baseline; an ES of 0.2, 0.5, and 0.8 was considered to be small, moderate, and large, respectively, for intra-group comparisons [25, 26].

Figure 1.

Flow diagram of the study.

3. Results

Fifty-three patients were eligible for this study. A total of 46 patients (mean $\pm$ SD: 52.10 $\pm$ 10.38 years; 26 females) satisfied all of the inclusion criteria. Five patients dropped out. Twenty patients in Group 1 (15 women) and 21 patients in Group 2 (11 women) were finally included in the analyses (Fig. 1). All of the patients received the allocated intervention. The mean age and body mass index of patients in Group 1 were 50.00 $\pm$ 11.23 years and 29.55 $\pm$ 5.03 kg/m ${}^{2}$ , respectively. The corresponding data for patients in Group 2 were 54.10 $\pm$ 9.34 years and 29.37 $\pm$ 5.77 kg/m ${}^{2}$ . The average duration of symptoms at the time of enrollment was 10.33 $\pm$ 9.39 months in Group 1 and 8.36 $\pm$ 8.62 months in Group 2 ( $p=$ 0.58). All of the baseline demographics were similar between groups ( $p>$ 0.05).

Table 1
Comparison of pain within the group and between groups

Assessment	Baseline	After 6 weeks		Effect	$P^{\ast}$	$P^{\ast\ast}$
(cm)	mean	Mean	Within-group score change	size	within-group	between groups
VAS-rest
Group 1	4.68 $\pm$ 2.47	3.47 $\pm$ 2.24	1.22 $\pm$ 2.10	0.48	0.02	0.21
Group 2	2.90 $\pm$ 2.97	3.00 $\pm$ 3.14	0.11 $\pm$ 1.65	0.03	0.77
VAS-activity
Group 1	7.75 $\pm$ 2.31	5.89 $\pm$ 2.72	1.89 $\pm$ 1.62	0.80	0.00	0.55
Group 2	6.71 $\pm$ 2.39	5.94 $\pm$ 3.35	0.77 $\pm$ 1.86	0.32	0.09
VAS-night
Group 1	6.90 $\pm$ 3.12	5.21 $\pm$ 3.89	1.73 $\pm$ 3.64	0.54	0.05	0.74
Group 2	6.67 $\pm$ 3.07	5.50 $\pm$ 3.18	0.50 $\pm$ 2.63	0.38	0.45

Abbreviations: VAS, visual analogue scale. Values are mean $\pm$ SD. ${}^{\ast}$ Paired sample $t$ -test. ${}^{\ast\ast}$ 2-by-2 mixed model analysis of variance.

Table 2

Comparison of ROM within the group and between groups

Assessment	Group	Baseline	6 weeks		Effect	$P^{\ast}$	$P^{\ast\ast}$
( ${}^{\circ}$ )		mean	Mean	Within-group score change	size	within-group	between groups
Flexion ROM	Group 1	139.65 $\pm$ 26.06	158.40 $\pm$ 20.76	18.75 $\pm$ 18.64	0.71	0.001	0.43
	Group 2	137.62 $\pm$ 23.74	148.75 $\pm$ 24.18	10.25 $\pm$ 22.08	0.46	0.05
Abduction	Group 1	119.95 $\pm$ 43.81	151.35 $\pm$ 36.12	31.40 $\pm$ 36.30	0.71	0.001	0.59
ROM	Group 2	116.95 $\pm$ 37.06	140.70 $\pm$ 39.13	22.20 $\pm$ 31.87	0.64	0.001
External	Group 1	50.70 $\pm$ 26.82	67.35 $\pm$ 22.29	16.65 $\pm$ 20.33	0.62	0.001	0.89
rotation ROM	Group 2	54.52 $\pm$ 19.14	64.0 $\pm$ 17.66	8.25 $\pm$ 17.09	0.49	0.04
Internal	Group 1	72.45 $\pm$ 22.36	81.65 $\pm$ 14.95	9.20 $\pm$ 16.64	0.41	0.02	0.41
rotation ROM	Group 2	69.29 $\pm$ 20.93	74.85 $\pm$ 20.97	5.30 $\pm$ 13.90	0.26	0.10

Abbreviations: ROM, Range of motion. Values are mean $\pm$ SD. ${}^{\ast}$ Paired sample $t$ -test. ${}^{\ast\ast}$ 2-by-2 mixed model analysis of variance.

Table 3

Comparison level of function within the group and between groups

Assessment	Group	Baseline	6 weeks		Effect	$P^{\ast}$	$P^{\ast\ast}$
		mean	Mean	Within-group score change	size	within-group	between groups
DASH	Group 1	45.21 $\pm$ 19.94	29.66 $\pm$ 20.60	$-$ 15.55 $\pm$ 22.79	0.77	0.01	0.50
	Group 2	48.43 $\pm$ 16.33	34.96 $\pm$ 24.75	$-$ 12.77 $\pm$ 21.54	0.82	0.01
ASES	Group 1	49.60 $\pm$ 19.47	70.26 $\pm$ 25.22	20.42 $\pm$ 30.97	1.06	0.01	0.72
	Group 2	51.85 $\pm$ 17.11	63.66 $\pm$ 24.92	13.70 $\pm$ 20.93	0.69	0.01
HAD-A	Group 1	9.43 $\pm$ 3.75	7.57 $\pm$ 4.99	$-$ 3.00 $\pm$ 4.50	0.49	0.69	0.14
	Group 2	8.55 $\pm$ 3.62	7.18 $\pm$ 4.33	$-$ 0.36 $\pm$ 1.74	0.37	0.50
HAD-D	Group 1	10.5 $\pm$ 20.9	9.0 $\pm$ 5.85	$-$ 1.85 $\pm$ 4.09	0.07	0.27	0.86
	Group 2	10.9 $\pm$ 3.87	10.27 $\pm$ 5.42	$-$ 0.09 $\pm$ 2.30	0.16	0.89

Abbreviations: DASH, The Disability of the Arm, Shoulder and Hand Questionnaire Scores; ASES, The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, HAD-A, The Hospital Anxiety and Depression Subscale-Anxiety; HAD-D, The Hospital Anxiety And Depression Subscale-Depression. Values are mean $\pm$ SD. ${}^{\ast}$ Paired Sample t-test. ${}^{\ast\ast}$ 2-by-2 mixed model analysis of variance.

Following the treatment, the groups did not exhibit significant differences in their changes in resting/activity/night pain, ROM, function, or anxiety and depression ( $p>$ 0.05) (Tables 1–3). An intra-group assessment revealed that VAS-rest ( $p=$ 0.02) and VAS-activity ( $p=$ 0.00) after 6 weeks improved in Group 1 (Table 1); there were no changes in rest/activity/night pain in Group 2 ( $p>$ 0.05) (Table 1). Abduction and external rotation ROM improved in both groups (Table 2); however, flexion and internal rotation ROM was increased only in Group 1 ( $p=$ 0.001 and $p=$ 0.02, respectively) (Table 2). The DASH and ASES scores improved in both groups ( $p=$ 0.01); the HAD-A and HAD-D scores did not improve in either of the groups ( $p>$ 0.05) (Table 3). The ESs of VAS, ROM, and ASES were larger in Group 1 compared with Group 2 (Tables 2 and 3).

Table 4

Comparison total number of active MTrPs within the group and between groups

Assessment	Group	Baseline	6 weeks		Effect	$P^{\ast}$	$P^{\ast\ast}$
		mean	Mean	Within-group score change	size	within-group	between groups
Triger point (active)	Group 1	4.30 $\pm$ 2.43	0.65 $\pm$ 1.30	0.65 $\pm$ 1.30	1.5	0.001	0.001
	Group 2	3.23 $\pm$ 0.53	2.66 $\pm$ 1.01	0.52 $\pm$ 1.20	1.07	0.07

Values are mean $\pm$ SD. ${}^{\ast}$ Paired sample $t$ -test. ${}^{\ast\ast}$ 2-by-2 mixed model analysis of variance.

The number of active trigger points were $n=$ 3 (7.3%) in the scalene, $n=$ 6 (14.6%) in the levator scapulae, $n=$ 14 (34.1%) in the upper trapezius, $n=$ 10 (24.4%) in the supraspinatus, $n=$ 9 (22%) in the infraspinatus, $n=$ 2 (4.9%) in the teres major, $n=$ 1 (2.4%) in the latissimus dorsi, $n=$ 14 (34.1%) in the anterior deltoid, $n=$ 3 (7.3%) in the posterior deltoid, $n=$ 10 (24.4%) in the subscapularis, $n=$ 8 (19.5%) in the pectoralis major, $n=$ 7 (17.1%) in the pectoralis minor and $n=$ 8 (19.5%) in the biceps brachii muscles in both groups. The number of muscles with active MTrPs was significantly lower in Group 1 than in Group 2 after 6 weeks ( $p=$ 0.001). The ES for active MTrPs after 6 weeks was 1.5, a large effect (Table 4). There was no adverse events or side effects in either intervention group after treatment.

4. Discussion

Even though both groups improved in terms of pain, ROM, and function, there were no differences in pain, ROM and function between the groups. However, the ESs of VAS, ROM, and ASES were larger in patients who received treatment of active MTrPs in addition to the standard conservative treatment program. Anxiety and depression level did not improve in either group.

Rotator cuff tears can be treated with many different methods such as exercise, mobilization, and electrotherapy modalities [27, 28, 29]. Several studies have noted the relevance of trigger points to shoulder pain [30]. such as impingement symptoms [31, 32]. A recent study reported that patients with shoulder pain derived from impingement symptoms had a higher pain intensity, a larger number of MTrPs, and lower pressure pain threshold levels than healthy controls [31]. The link between active MTrPs and symptoms of rotator cuff tears is not well known. Hains et al. [7] studied the effectiveness of IC of MTrPs in shoulder muscles in patients with chronic shoulder conditions compared with a placebo compression group and a control group. In addition, Bron et al. [5] pointed out that patients with non-traumatic shoulder pain had less pain after 12 sessions of treatment for MTrPs than patients who did not receive any treatment. According to these findings, clinically relevant improvements were achieved in 55% of patients with shoulder pain, and the number of muscles with active MTrPs significantly decreased. Similarly, our patients received 12 sessions of IC treatment, and improvements in pain were significantly higher in patients who received treatment of active MTrPs in addition to the standard conservative treatment program. However, we did not attain the minimal clinically important difference of VAS, which has been reported to be 2.17 points [22]. Because trigger points may be one of the sources of shoulder pain, MTrP treatment was applied in addition to a standard conservative treatment program. Placebo compression or no intervention has been applied in studies that investigated the effectiveness of MTrP treatment in pain related to shoulder pathologies for comparison. Therefore, we could not find any study to directly compare with our investigation.

Hypotheses exist that the treatment of trigger points will increase joint motion by loosening the muscles involved in shoulder pathologies. However, no studies have yet tested these hypotheses. Bron et al. [5] reported that a treatment consisting of manual compression of MTrPs, manual stretching of muscles, and intermittent cold application with stretching did not significantly change shoulder ROM in patients with chronic shoulder pain compared with a control group. In our study, ROM improved in both groups whereas flexion and internal rotation ROM only in patients received IC technique. Furthermore, the ES of ROM was larger in patients who received the IC technique than in other patients. It is difficult to argue that this small improvement in these patients is only due to trigger point treatment because the patients in our study also received stretching and strengthening exercises to gain ROM.

In studies investigating trigger point treatment in shoulder pathologies, function was assessed using DASH and Shouder and Pain Disability Index (SPADI) scores [22]. Studies that included 12 weeks of MTrP treatment showed that DASH was significantly improved compared with patients in the control group [5, 23]. However, the 7.7-point improvement did not attain the minimal clinically important difference of DASH, which is around 10 points [5, 23]. Hains et al. [7] applied the IC to MTrPs in patients with chronic shoulder pain over the course of 15 sessions. These authors found that patients in the treatment group exhibited a significant reduction in their SPADI scores compared with patients in the control group. We used DASH and ASES scores to evaluate the function of the patients. Our results supported this literature for function parameters following treatments for both groups. In addition, both groups attained the minimal clinical significance for the DASH and ASES scores. On the other hand, the scores of one group were not superior to the other.

People who often experience stress or depression may be more prone to develop MTrPs in their muscles [33]. One theory maintains that such people stress their muscles, leading to a form of repeated strain that leaves their muscles susceptible to MTrPs [33]. However, the relationship between psychological conditions and MTrPs is not yet fully understood. Celik and Nutlu [11] found that patients’ scores on the Beck Depression Inventory increased with the number of latent MTrPs. These authors noted the possibility of stress or depression management being a form of treatment for latent MTrPs [11]. We investigated the anxiety and depression level of patients with HAD scores. Patients who received the active MTrP treatment did not differ in their HAD scores compared with patients who were administered the standard conservative treatment only. Furthermore, the anxiety and depression subscales were not improved in either group. The HAD is a measure of anxiety and depression in patients with somatic disease [19, 20]. However, the use of this scale does not appear to be an appropriate choice for patients with rotator cuff tears. We believe that using different scales to assess anxiety and depression might affect these results eventually.

Our results indicated that a reduction in pain may be associated with a reduction in the number of trigger points, which is one of the major goals of MTrP treatment [5]. Rotator cuff weakness results in upward migration of the humeral head. In addition, weakness of the serratus anterior and lower trapezius muscles limits scapular upward rotation and leads to compensatory activation of the upper trapezius muscle. Over the long term, this situation sets the stage for fatigue, tightness, and MTrPs in the upper trapezius muscle [34]. All these mechanisms may lead to more trigger points in the upper trapezius muscle, as we found. The IC treatment led to a decrease in the number of MTrPs in the upper trapezius. However, this decrease was not statistically significant [35].

This study has several strengths. Besides being a double-blind, randomized, and controlled trial, it is the first study to report the relationship between the standard conservative treatment and standard conservative treatment in addition to IC therapy of active MTrPs in patients with rotator cuff tears. However, this study also has some limitations. A larger number of participants might have enabled a positive detection of progress in the group receiving the active MTrP treatment. Second, there was no control group, which could have provided a control for the condition’s natural healing process. Third, this study had a short-term follow-up period. Fourth, pain intensity was assessed by VAS rather than algometer. Besides, the change in inequivalence in the VAS-rest at baseline potentially could inflate the results; however, the 2-by-2 mixed model ANOVA controls for a baseline. Therefore, we believe that our results are likely statistically robust. Additional studies need to be conducted with larger patient cohorts in order to confirm the effectiveness of active MTrP treatment in rotator cuff pathologies.

5. Conclusion

A standard conservative treatment program increases function and ROM in patients with rotator cuff pathologies. However, the addition of MTrP treatment to the conservative program did not improve clinical outcomes (resting/activity/night pain, ROM, function, and anxiety and depression) in patients with rotator cuff pathologies. Even so, the inclusion of trigger point treatment in patients with rotator cuff pathologies may lead to results that are more positive in terms of pain management. Additionally, the treatment of MTrPs reduces the total number of active MTrPs.

Footnotes

Conflict of interest

The authors have no conflict of interest to declare.

Appendix

1–7 days

ROM: Active assistive ROM and wand exercise in the supine position:

•

Flexion

•

Abduction

•

Scapular adduction

•

External rotation

•

Internal rotation

Stretching (passive) exercises

•

Pectoralis minor muscle

•

Upper trapezius muscle

7–14 days

•

Continue with previous exercises

•

Wand exercises in the standing position

•

External rotation in side-lying position

•

Pulley exercises (flexion and abduction) in sitting on a chair

•

Posterior capsule stretching

14–21 days

•

Continue with previous exercises

•

Distraction, traction, gliding exercises

•

Middle/lower trapezius strengthening exercise with the elastic band

•

Upper/lower trapezius self-stretching exercise

21–28 days

•

The exercises progressed increasing the repetition number

•

External rotation with 0.5 kilograms in the side-lying position

•

Elevation on scapular position (90 ${}^{\circ}$ )

28–35 days

•

Scapular adduction exercise in the prone-lying position

35–42 days

•

Middle/lower trapezius strengthening exercise in the prone-lying position

•

Push-up exercise in the sitting position

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