Dr. Dale Buchberger’s Frozen Shoulder Protocol – Conservative Rehabilitation Program

The rehabilitation for Frozen shoulder resulting in reduced motion of the humeral head will vary in length depending on factors such as:

  1. Degree of shoulder contracture.
  2. Acute versus chronic condition.
  3. Strength and ROM status.
  4. Underlying Impingement signs present or absent.
  5. Performance and activity demands.
  6. Muscle endurance.
  7. Length of time immobilized.
  8. History of past trauma (primary or secondary FSS).

The rehabilitation program is outlined in Three Phases. It is possible to overlap phases (phases 1-2, 2-3, etc.) depending on the progress of each individual. In all exercises during Phase I and Phase II, caution must be applied in preventing excessive superior translation of the humeral head as joint ROM is restored. The focus in Phase III is on progressive isotonic exercises in preparation for returning to the prior activity level (work, recreational activity, sports, etc.).


  1. Apply modalities as needed (heat, ice, EMS, US, etc.). Keep this to a maximum of 10-14 days.
  2. Active Release Techniques and/or SASTM (Sound Assisted Soft Tissue Mobilization) to reduce soft tissue restrictions:
    1. Anterior, Inferior and Posterior capsule
    2. RTC muscles (Including the subscapularis)
    3. Triceps at T. Major and Minor
    4. Anterior and Posterior deltoid at the infraspinatus
    5. Latissimus Dorsi
    6. Rhomboids, Levatore Scapulae
    7. It helps to apply the SASTM (Sound Assisted Soft Tissue Mobilization) to the Deltoid and RTC muscles for the first 4-6 visits. ART is phased in around visit 3-4 and is applied within the patients pain free ROM.
  3. Perform range of motion (ROM) exercises (passive, active-assisted, active) as tolerated. For shoulder abduction and ER, avoid excessive pain production by positioning the shoulder in the scapular plane (approximately 20-30 degrees forward of the coronal plane).
    1. Passive D1 PNF patterns (office)
    2. Passive D2 PNF patterns in side posture within the patients ROM and pain tolerance. (Office)
    3. Manual resistance: IR/ER in scapular plane 20-30 degrees FF supine to tolerance with end range stretch (office)
    4. Codman’s pendulum exercises: 50 circles clockwise, 50 circles counterclockwise and 50 figure-8’s; repeat qid (home).
  4. Shoulder stretch: posterior rotator cuff (RTC)/capsule to tolerance.
    1. Horizontal adduction with scapular stabilization supine (office) the patient may not be able to assume the 90/90 position D/T tight capsule. Work with them and modify as necessary.
    2. WWF interlock supine (office) Go SLOW!
    3. Behind the back elbow push prone (office) if the patient can place the back of their hand on their ipsilateral buttock.
    4. Horizontal adduction with distraction standing (home) may have to start with thumb up (ER) and progress to thumbs down (IR).
    5. Behind the back stretch with baseball bat or golf club with supported anterior shoulder standing (home)
  5. Mobilization: posterior glides, caudal glides and figure 8’s as needed.
  6. Long axis distraction (LAD’s): 30s each repeat 5-10 times at the end of the treatment session.
  7. Scapular stabilization exercises
    1. RS for the GHJ (short lever) and Scapula. This is to restore proprioception in the GHJ capsule. Perform short lever GHJ RS supine with HMP placed anterior and posterior on the GHJ. When RS are finished remove HMP, approximately 10 minutes.
      1. Start with eyes open and supported. Progress with patient ability to eyes closed and unsupported.
    2. Quadrupeds with plus to strengthen and coordinate the Serratus anterior as well as auto mobilize the capsule. Be sure to allow passive retraction. Good patient instruction is important here. This auto mobilization technique is key to restoring ROM and capsular freedom.
    3. Seated scapular pinches 10sx10 qid (“elbows in the back pockets”). Be sure to have elbows go down and back into the hip pockets to stimulate the lower trapezius.
    4. Supine Cervical retractions 10sx10 tid Chin tuck and push head straight back into the floor. Once chin tuck is established be sure NOT to extend the cervical spine. Perform chin tuck and straight retraction of the cervical spine.
  8. Active isometric strengthening exercises for shoulder IR and ER standing. Use multiple angles. The shoulder position and intensity may be adjusted to allow a pain free muscle contraction to occur. All isometrics should be performed with a scapular set (retracted/depressed scapula).
  9. Active isometric strengthening for FF, ABD, EXT, ADD with fully extended elbow. Extension should be performed with the palm forward and palm backward.
    1. Perform all isometrics 10s hold 10x’s qid for each motion.
    2. Add the Side lying abduction (side lying lateral raise in the “Costanza” position) exercise if it can be performed without a shoulder shrug. If shrug occurs continue other exercises until shrug is absent, then incorporate side lying abduction.
  10. Triceps Kickbacks: Can be added to the program early in the treatment. Towel in Axilla. Bent over row position. Humerus (upper arm) parallel to the floor. All motion occurs at the elbow. Extend the elbow with the thumb pointing to the floor. The second repetition with the palm to the floor. Alternate hand position on each repetition. This exercise develops the triceps muscle while providing co-contraction to the RTC and GHJ. The GHJ is not moving during this exercise so it can be added to the program very early with minimal to no risk of exacerbation or re-injury. Squeezing the towel in the axilla helps mobilize the GHJ.
  11. Active shoulder IR/ER: As strength and ROM improves progress from isometrics to hand weights.
    1. Shoulder IR: perform side-lying with the involved side resting on the scapula. Elevate or support the lateral chest wall (pillow, wedge, etc.) to decrease the joint compression on the involved shoulder. Follow progression from modified to dumbbell with tubing.
    2. Shoulder ER: Lie on the uninvolved side. Start with Modified ER position and progress to full side posture ER with dumbbell and tubing. Turn the thumb backward (hitchhiker) at the end on ROM.
  12. Add forearm-strengthening exercises (elbow and wrist):
    1. Hammer curls (brachioradialis)
    2. Elbow flexion with eccentric (ECRL/Brachioradialis)
    3. Pronation/supination
    4. Radial/ulnar deviation
    5. Hand gripping exercises (Hand master)
    6. Wrist roller (flexion/extension and pronation/supination)


  1. Continue posterior RTC/capsule stretch, mobilization and ROM exercises as needed.
    1. Add Triceps stretch/inferior capsule stretch Dr. assisted supine and standing with bat or golf club
    2. Add Pec minor and anterior capsule stretch on doorway.
  2. Discontinue isometrics.
  3. Advance RS to long lever positions and functional positions of abduction and rotation.
  4. Continue shoulder strengthening by adding surgical tubing to selected exercises. Continue with previous dumbbell exercises. Emphasize eccentric phase of contraction for the RTC. Add:
    1. Concentric/eccentric ER exercise in side posture within patients available ROM.
    2. BB1 and BB2 with scapular set.
  5. Add arm ergometer for endurance exercise if available.
  6. Add push-up position with plus: Can also hold dumbbells to reduce wrist discomfort. Assume push-up position. Protract scapulas (plus position). Hold 10 seconds, relax, causing, passive scapular retraction. On the plus be sure not to flex the thoracic spine. All motion should occur at the Scapulothoracic articulation (scapula). Keep the spine and torso rigid. Repeat 10-25 times 2-3 times per day.
  7. Add total body conditioning with emphasis on strength and endurance. Include flexibility exercises as needed. Protect the kinetic chain!
    1. Lawn mower exercise for the lower trapezius.
    2. Life cycle, treadmill, stair stepper, etc.


  1. Continue posterior RTC/capsule stretching as needed.
  2. Continue scapular stabilizing exercises.
    1. Assess scapular setting on Blackburn series for superior shrug. If the superior shrug is present correct for this.
  3. Continue to emphasize the eccentric phase in strengthening the RTC.
    1. Add BB3 with palm down to start as patient performs correctly progress to BB3 with thumb up to the ceiling. Either maneuver is preceded with a scapular set.
    2. Subscapularis pull with tubing behind the back. Keep tubing light on this exercise and emphasize ROM and repetitions.
  4. Add side bridging for total arm strength (TAS):
    1. Even surface (stable)
    2. Uneven surface (unstable) using a dyna-fit pad or the like.
  5. Continue total body conditioning with emphasis on the RTC.
  6. Progress RTC strengthening as patient gains competence in performing BB1, 2, and 3.
    1. Add BB4 concentrically. DO NOT scapular set on this exercise.
    2. In the office work with the patient on BB4 Eccentrically. Use 2x the concentric weight. For example: If the patient can perform BB4 concentrically with 3 pounds use six pounds for the eccentric.
    3. Add modified empty can once Side lying abduction (SLA) and BB4 can be performed with excellent technique and 3#’s 3 sets 30 reps.
      1. Modified Empty Can: Elevation in the scapular plane (Scaption) with the thumb pointing to the floor to 45 degrees of elevation. At this point begin external rotation of the humerus slowly and controlled. Return to the start by reversing the motions.
  7. Add Weight training exercises in association with the patients life style and goals of outcome.