Comparing the Effectiveness of Manual and Self-Applied Inferior Glenohumeral Joint

Mobilizations Using Ultrasound Imaging

Authors: Raegan Hickok, Catherine Stump, & Sydney Wynne

Research Advisor: John M. Andraka PT, DPT, PhD

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, MI

April 15th, 2024

Submitted to the Faculty of the

Doctoral of Physical Therapy at
Central Michigan University
In partial fulfillment of the requirements of the
Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

John Andraka, PT, DPT, PhD

Date of Approval: April 15, 2024
ABSTRACT

Objective: Shoulder pathologies such as adhesive capsulitis and subacromial impingement

syndrome have increasing prevalence and patients are commonly seeking treatment for these
conditions. One common intervention for addressing glenohumeral (GH) joint hypomobility
associated with these diagnoses is joint mobilization. We hypothesized that manual inferior GH
joint mobilizations would be significantly more effective when compared to commonly
prescribed self-mobilizations. Moreover, since inferior GHJ self-mobilizations require gripping
leading to involuntary rotator cuff muscle activation and proximal stabilization, we suspected
that minimal to no inferior GHJ accessory gliding would be detected. The purpose of this study
was to compare the effectiveness of two commonly prescribed inferiorly directed joint
mobilizations by measuring acromiohumeral distance (AHD) using ultrasound imaging.
Design: Within-subject, repeated measures design
Methods: Nineteen healthy adults (12 females, 7 males; 22.9 ± 1.2 years) volunteered to
participate. Inferiorly directed self-mobilizations and clinician-applied manual mobilizations were
applied twice in a randomized order to each upper extremity with a consistent traction force of 15%
body weight. AHD was measured via ultrasound imaging at rest and during the two test conditions.
The transducer was placed at the anterolateral border of the acromion and the subacromial space
was clearly visualized. All ultrasound images were saved, and AHD, defined as the 30-degree angle
between the most superior point of the acromion to the superior border of the humeral head, was
later measured by one blinded assessor at rest (baseline) and during both mobilization conditions.
Results: Intraclass correlation coefficient (ICC) for test-retest reliability of AHD measurements at
baseline and during both mobilization test conditions was excellent ranging from 0.876-0.963.
Differences in AHD (mobilization – baseline) were compared using paired t-tests and reported as
mean ± SEM. Differences in AHD during clinician-applied mobilizations (3.90 ± 0.51 mm) were
significantly greater (p < 0.0001) than self-mobilizations (1.68 ± 0.49 mm). No significant
differences were observed comparing clinician-applied mobilizations amongst genders (female:
3.16 ± 0.58 mm; male: 5.15 ± 0.90 mm, p = 0.060). However, there was a statistically significant
difference when comparing female and male self-mobilizations. (female: 0.88 ± 0.51 mm; male:
3.05 ± 0.90 mm, p = 0.029).
Conclusion: First, our AHD measurement methodology was found to have excellent reliability. In
addition, clinician-applied manual GH joint mobilizations was a significantly more effective
method of creating inferior humeral accessory translation when compared to a commonly
prescribed self-mobilization technique. In fact, AHD was unchanged or less than resting baseline
measurements in almost one-third of participants. Although self-mobilizations of the GH joint are
commonly described in physical therapy educational and clinical resources, our findings question
the effectiveness and usefulness of prescribing GH joint inferior self-mobilizations and place
importance of a clinician using time in the clinic perform specific applied GHJ mobilizations.
KEY WORDS: Glenohumeral joint, joint mobilizations, subacromial space, ultrasound,
acromiohumeral
INTRODUCTION

Pathologies of the shoulder complex are the third most prevalent condition seen in

orthopedic clinical settings. An estimated 26% of individuals will experience shoulder pain and

dysfunction during their lifetimes, and the incidence has only increased in recent years post-Covid

with diagnoses such as adhesive capsulitis increasing by 39.7%4, 14. Other common shoulder

pathologies include osteoarthritis and subacromial impingement syndrome 3. Interventions aimed

at addressing glenohumeral (GH) capsular restriction are a key feature of clinical management of

these common shoulder pathologies. One frequently implemented treatment strategy for patients

presenting with GH hypomobility is joint mobilization. Manual joint mobilizations (MJM) make

a significant difference in range of motion compared to exercise alone when applied to shoulder

pathologies involving the GH joint and therefore have become a standard in shoulder treatment 14,
16
.

Joint mobilizations or arthrokinematic glides, involve translation of articulating surfaces in

a rhythmic oscillatory pattern or sustained hold, often prescribed with the intent of pain modulation

or increasing joint range of motion (ROM) 5, 14. Due to the shallow concavity of the glenoid fossa,

the GH joint has a relatively large amount of translational glide. However, patients with shoulder

pathology and hypomobility may exhibit a significant decrease in accessory movement and limited

joint ROM 8. According to Cyriax’s capsular pattern of restriction, the GH joint loses ROM in the

order of external rotation, abduction, then internal rotation 9. Theoretically, these osteokinematic

motions can improve by mobilizing the joint into the motion’s corresponding translational glide.

For example, to improve the osteokinematic motion of shoulder abduction, an inferior translational

joint glide would be indicated. Due to the effectiveness of GH joint mobilizations, clinical

intervention strategies often incorporate clinician applied MJM and self-joint mobilizations (SJM)

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to address shoulder mobility restrictions. In fact, patients are commonly prescribed SJM of the GH

joint, which are described in various clinical resources including textbooks utilized in physical

therapy education and exam preparation materials for the national physical therapy licensure exam
7
. Additionally, SJM techniques are found on websites frequently used by clinicians for exercise

and home exercise prescription such as HEP2Go.com and Medbridge.com. SJMs are meant to

mimic MJM administered by physical therapists, but the effectiveness is questionable. Indeed,

gripping activities cause involuntary activation of proximal upper extremity and rotator cuff
2, 6, 13
muscles . This involuntary proximal muscle activation improves dynamic stability of the

shoulder complex, however, also brings into question the effectiveness of inferiorly directed self-

mobilizations achieved by gripping the chair surface (FIGURE 1B).

Therefore, we hypothesized that applying an inferiorly directed MJM will produce

significantly greater translatory joint gliding and increase acromiohumeral distance (AHD) when

compared to a SJM technique in healthy participants. Moreover, since inferior GH SJM requires

gripping leading to involuntary rotator cuff muscle activation, we suspected that minimal to no

inferior GH accessory gliding would be detected. Our research aim is to measure the change in

AHD by comparing baseline with MJM and SJM distances utilizing ultrasound imaging to

compare the effectiveness of these two GH joint mobilization techniques.

METHODS

Study Design and Participants

Nineteen healthy college students (12 females, 7 males; Mean Age: 22.9 ± 1.2) with no

previous or current shoulder pathology volunteered for this study. Participants between 18-28

years old were recruited by posted flyers on campus and word-of-mouth. Subjects completed an

intake questionnaire and were medically screened for shoulder pathology by a licensed, orthopedic

2
physical therapist (JA) with 20 years of clinical experience to determine eligibility for

participation. Information obtained from the participant included name, age, hand dominance,

weight, past medical history, and history of shoulder injury. Testing was completed at the Carls

Center Physical Therapy Clinic on the campus of Central Michigan University. This study was

approved through the Institutional Review Board at Central Michigan University and informed

consent was obtained from all participants prior to testing.

Procedure

Participants warmed up on an upper body ergometer (Schwinn Fitness Inc, Louisville, CO)

for three minutes at 50 revolutions per minute. Testing order for arm and mobilization technique

was randomized by a coin flip. Participants sat in a firm wooden chair for both the MJM (FIGURE

1A) and SJM (FIGURE 1B). techniques. The three testing conditions consisted of baseline testing

(BT), MJM, and SJM. Two trials were taken of each condition bilaterally, for 6 trials per arm or

12 per participant. During the MJM testing condition, a Velcro strap was firmly attached to the

participant’s distal humerus just proximal to the epicondyles. A digital handheld dynamometer

(SF-500, ELEOPTION, Beijing) was attached via hook to the strap and the interventionist slowly

applied increasing inferiorly directed traction force to the dynamometer until 15% BW was

reached (FIGURE ID). The patient was instructed to relax to limit muscle contraction in the tested

upper extremity. During the SJM testing condition, the patient gripped the pull dynamometer,

which was secured to a wooden board on the floor (FIGURE 1E). This set up was intended to

simulate the typically prescribed seated, inferior self-mobilization, where the patient would grip

the seat surface. The participant was instructed to relax their involved shoulder as much as possible

while leaning their trunk to the contralateral side until reaching the same 15% BW traction force.

The interventionist and verbal cueing were consistent between trials and participants. Each

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mobilization was held for 30-second which allowed ample time for imaging and mobilization force

was consistently 15% of body weight measured by digitized pull dynamometer for consistency.

Musculoskeletal ultrasound (MSKUS) imaging (Logic E Ultrasound, General Electric,

Boston, MA) measured AHD during the two trials of each testing condition (BT, MJM, SJM). The

transducer was placed at the anterolateral border of the acromion for each image. AHD was

measured by identifying the most superior point on the lateral acromion, then extending a line 30⁰

from vertical to the superior aspect of the humeral head (FIGURE 2). Still images for each of the

three testing conditions were saved (FIGURE 3), and AHD was later measured by a one blinded

member of our research team.

Data Analysis

Descriptive statistics were completed using Microsoft Excel (Microsoft Corporation,

Redmond, Washington) and was reported as mean ± standard error (SE) in millimeters (mm). The

remaining data analyses were completed with SPSS Version 29.0 (IBM, Armonk, New York.).

Intraclass correlation coefficient (ICC) and minimal detectable change (MDC) at 95% confidence

interval were calculated to determine reliability of our AHD measurement methodology while

paired t-tests with p < 0.05 were utilized to compare AHD between testing conditions.

RESULTS

Nineteen individuals (12 females, 7 males) with a mean age of 22.9 ± 1.2 years, and weight

of 163.97 ± 36.5 pounds participated. Hand dominance was 17 right-handed and 2 left-handed

participants.

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Reliability of Acromiohumeral Distance (AHD) Measurements

The ICC for test-retest reliability for all test conditions was deemed excellent with the ICC

values ranging from 0.876-0.963. MDC at 95% confidence interval ranged from 0.8-2.3 mm when

measuring AHD using diagnostic ultrasound imaging (TABLE).

Changes in AHD during MJM and SJM: All Data

Overall, when comparing changes in AHD measurements during MJM and SJM, a

statistically significant difference was identified. The mean change in AHD during MJM (3.90 ±

0.51 mm) was significantly greater than the change in SJM (1.68 ± 0.49 mm, p < 0.001). Moreover,

the increase in AHD during MJM exceeded MDC95, indicating a true change, unlike changes in

AHD during SJM (FIGURE 4).

Changes in AHD during MJM and SJM: Dominant to Non-Dominant

A statistically significant difference was identified when comparing right shoulder MJM

(4.40 ± 0.90 mm) compared to the SJM (1.96 ± 0.64 mm, p = 0.004). Similarly, AHD on the left

shoulder during MJM (3.39 ± 0.49 mm) was significantly greater than during SJM (1.40 ± 0.75, p

= 0.006) (FIGURE 4).

Changes in AHD during MJM and SJM: Gender

Results varied when examining the differences in AHD between male and female

participants. When comparing AHD during MJM in females (3.16 ± 0.58 mm) to ADH in males

during MJM (5.15 ± 0.90 mm, p = 0.060), no significant difference was the identified. However,

AHD in females during SJM (0.88 ± 0.51mm) was compared to AHD in males during SJM (3.05

± 0.90 mm, p = 0.029), males demonstrated a greater statistically significant change in AHD.

Interestingly, AHD during SJM in males was over three times greater than in the females

(FIGURE 5).

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DISCUSSION

The aim of this study was to compare the effectiveness of clinician-applied and self-applied

inferior joint mobilizations by measuring AHD distance utilizing ultrasound imaging. We

hypothesized that MJM would be substantially more effective when compared to SJM techniques

commonly depicted in clinical resources and advocated in clinical settings. For example, inferior

GH joint mobilizations are frequently prescribed to treat hypomobility associated with adhesive

capsulitis and to increase AHD to address pain associated with subacromial impingement

syndrome (Do Moon G, Lim JY, Kim DY, Kim TH). As expected, MJM resulted in significantly

greater AHD than SJM when comparing all AHD measurements (FIGURE 4). In fact, not only

were clinician-applied MJM more effective, approximately 30% of participants performing SJM

demonstrated no change or a decrease in AHD (FIGURE 3). While this study did not investigate

specific reasons for this finding, we suspect that the significantly decreased inferior translatory

glide and the nearly one-third of participants who demonstrated a reduced AHD during SJM force

application was likely due to involuntary proximal musculature and rotator cuff activation

associated with gripping. Indeed, several studies have reported increased proximal muscle activity

associated with fine motor and gripping activities 2, 6, 13. Anticipatory postural control, a concept

of motor control that describes muscle activation as a result of anticipated change in body position,

may also play a role 11. Our results are clinically meaningful since inferior SJM are commonly

prescribed to patients as a follow-up or adjunct treatment to other mobility interventions intended

to increase GH capsular tissue extensibility. According to our findings, self-mobilization may not

be in the best interest of patients and may not sufficiently meet the goal of improving capsular

tissue extensibility and ultimately GH joint mobility.

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 Despite the multiple aspects of measuring AHD described in our methodology, the

reliability of AHD measurements utilizing ultrasound imaging for this study was overall found to

be excellent. Multiple aspects of our methodology including consistent clinician and self-

mobilization force over multiple trials, US imaging proficiency, and collecting linear AHD

measurements, had the potential to introduce error (TABLE). Moreover, following extensive

training, all aspects of data collection, including ultrasound imaging and AHD measurements were

completed by 3rd year student physical therapists, which makes our excellent reliability findings

even more noteworthy. Test-retest reliability (ICC) comparing repeat trials of right and left BT,

MJM, and SJM ranged from 0.876-0.963 (TABLE). Several aspects of our methodology

undoubtedly contributed to excellent reliability. Manual and self-mobilization force was

standardized to 15% body weight and continually monitored with a digital dynamometer.

Considering connective tissue viscoelasticity, mobilization force hold time was 30-seconds with

US image capture typically occurring at the greatest capsular stretch achieved. During SJM, an

assessor monitored the dynamometer and gave constant feedback to participants to increase,

decrease, or maintain force levels while US imaging was completed. Likewise, the interventionist

continuously monitored the dynamometer during traction force application. Additionally, AHD

was clearly defined. AHD was measured by identifying the most superior point on the lateral

acromion, then extending a line 30⁰ from vertical to the superior aspect of the humeral head. This

well-defined operational definition allowed the blinded assessor to consistently measure AHD at

rest (BT) and during the two testing conditions (SJM & MJM). Considering the above attributes,

we feel that our methodology can be reliability replicated in future research.

We were also interested in comparing changes in AHD during MJM and SJM between

genders. Interestingly, males demonstrated a significantly greater AHD compared to their female

7
counterparts during both MJM and SJM. These results were unexpected because females typically

present clinically with increased capsuloligamentous laxity and joint mobility when compared to

male counterparts. In a literature review performed by Wright et al 15, the authors emphasized that

young female athletes are more likely to experience shoulder pathology due to shoulder

capsuloligamentous laxity. Indeed, there are a multitude of hypotheses including fluctuating

hormonal and estrogen levels associated with menstruation that attempt to explain decreased tissue

stiffness in females 1, 12. Thus, this research begs the question, are there differences in females as

compared to males that also leads to increased involuntary muscle guarding during mobilizations?

The results of this study demonstrating decreased AHD in females during MJM and SJM could be

due to multiple factors including menstruation induced hormone fluctuation, hypermobility

10
prevalence in females, or anatomical characteristics. In a study performed by Merrill et al ,

anatomical differences were identified in the glenoid when looking at males versus females, which

supports the idea that the decrease in subacromial space seen in this research may have been due

to the variability in glenoid shape and anatomy present in females. The origins of gender-based

differences in AHD identified in our study warrant further investigation.

Several other strengths of our methodology are worth noting. Testing order of shoulder

(Right vs. Left) and mobilization technique (MJM vs. SJM) were randomized by coin flip to

minimize “order effect” associated with repeated measures. Moreover, still images of the

subacromial space were taken at rest and during mobilization force application. The assessor

responsible for quantifying AHD measured at a later date and was blinded to participant, order,

shoulder and mobilization technique. Finally, the study sample was homogenous which improves

internal validity, while admittedly decreasing generalizability. Participants were healthy, young

adults with no current or history of shoulder pathology, who were similar in age (22.9 ± 1.2 years),

8
somatotype and body weight (163.9 ± 36.6 pounds). In addition, we chose to compare the change

in AHD during SJM and SJM compared to baseline AHD, rather than simply comparing AHD

during joint mobilization techniques. This approach intended to account for the likely variability

in resting humeral head position and AHD, resulting in a more accurate assessment of humeral

translation during mobilization force application. While limitations exist in any research design,

we feel that multiple aspects of our methodology and data collection were appropriate, thoughtful,

and improve the validity of our findings.

This research study has potential limitations that should be identified. Although the digital

dynamometer was continuously monitored, maintaining an exact traction force throughout

mobilizations was not possible. Thus, the force applied by the interventionist during MJM or the

participant during SJM varied slightly. However, given the excellent reliability reported, this may

be a moot point. Moreover, we theorize that involuntary rotator cuff activation and proximal joint

stabilization due to gripping during the SJM contributed to its lack of effectiveness (FIGURE 3).

This could have been confirmed with surface EMG of the supraspinatus, infraspinatus, teres minor

and deltoid muscles, however this technology was not available to us as clinical researchers.

Another limitation present in this research was the use of healthy, young subjects. All participants

were free of shoulder pathology and hypomobility. This may be perceived as limiting applicability

to clinical practice and pathological populations. However, the opposite could be deduced. Perhaps

testing on painful, pathological shoulders would increase involuntary proximal muscle guarding,

especially during SJM, further lessening the effectiveness of this mobilization technique. Indeed,

this is speculation on our part, but our methodology and findings in healthy subjects should serve

as guidance for future research on subjects with shoulder pathology.

9
 Future research should include incorporating EMG to measure and compare rotator cuff

and proximal muscle activation during MJM and SJM. Moreover, we believe it would be beneficial

to explore the impact of varying mobilization force on AHD to determine if an “optimal” force

level can be identified to maximize effectiveness of MJM and especially SJM. Lastly, considering

that SJM are commonly prescribed for various joints and evidence of involuntary proximal muscle

activation, we would be intrigued to measure joint accessory motion using ultrasound imaging in

other regions of the body.

CONCLUSION

In conclusion, clinician applied MJM was a significantly more effective method of creating

inferior humeral accessory translation when compared to a commonly prescribed SJM technique.

In fact, during SJM AHD was unchanged or less than resting baseline measurements in almost one

third of participants. Although EMG data was not collected, this is likely due to the involuntary

rotator cuff activation that occurs with gripping during SJMs. In addition, our AHD measurement

methodology was found to have excellent reliability, strengthening interpretation of our findings.

Although commonly described in physical therapy educational and clinical resources, our findings

question the usefulness of prescribing self-applied inferior GH joint mobilizations.

10
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APPENDIX A

TABLE. Intraclass correlation coefficient (ICC) and

minimal detectable change at 95% confidence interval
(MDC95) for repeated AHD measurements utilizing
ultrasound imaging. (*p < 0.001.) Abbreviations:
AHD, acromiohumeral distance
APPENDIX B

FIGURE 1. Participant positioning and equipment setup during (A)

MJM and (B) SJM conditions; (C) Ultrasound transducer placement
measuring AHD over anterolateral border of the acromion and humeral
head; (D/E) MJM and SJM force application setup, respectively.
Abbreviations: AHD, acromio-humeral distance; MJM, manual joint
mobilization; SJM, self joint mobilization
APPENDIX C

FIGURE 2: Ultrasound image of acromiohumeral distance (AHD) measurement.

(1) Superior border of acromion; (2) cortical line of humeral head; (3) AHD
defined as a 30-degree angle between the most superior point of the acromion to
the superior border of the humeral head; (4) AHD measurement
APPENDIX D

FIGURE 3. Ultrasound images of AHD at rest/baseline and during SJM and

MJM. (A) BT; (B) SJM, (C) MJM. Note the decrease in AHD from baseline to
SJM force application and the increase in AHD during MJM. Abbreviations: BT,
baseline testing; SJM, self-joint mobilization; MJM, manual joint mobilization
APPENDIX E

FIGURE 4. Comparing changes in AHD during MJM and SJM.

Mean change in AHD reported for right and left shoulders, and
combined data. Error bars represent SE. (*p < 0.001, ** p < 0.01).
Abbreviations: AHD, acromiohumeral distance; SJM, self-joint
mobilization; MJM, manual joint mobilization
APPENDIX F

FIGURE 5. Comparing AHD differences during MJM

and SJM in male and female participants. Error Bars
represent SE. (*p < 0.05.). Abbreviations: AHD,
acromiohumeral distance; SJM, self-joint mobilization;
MJM, manual joint mobilization