Frozen Shoulder

Welcome to Texas State University's Evidence-based Practice project space. This is a wiki created by and for the students in the Doctor of Physical Therapy program at Texas State University - San Marcos. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Dawn Waugh

Lead Editors - Sarah Grafelman,

Search Strategy

Databases Searched: EBSCOhost, PubMed, CINHAL

Keywords Searched: Adhesive capsulitis, conservative management, frozen shoulder, shoulder pathologies, shoulder disorders, functional outcomes, manual therapy techniques,

Search Timeline: 10/4/2010 - 11/23/2010

Definition/Description

By definition, adhesive capsulitis is a benign, self-limiting condition of unknown etiology characterized by painful and limited active and passive glenohumeral range of motion of ≥ 25% in at least two directions most notably shoulder abduction and external rotation.

Adhesive capsulitis, commonly referred to as frozen shoulder, is associated with synovitis and capsular contracture and can be classified as either primary or secondary . Frozen shoulder is considered primary if the onset is insidious while secondary is thought to be a result of another disease process. Three subcategories of secondary frozen shoulder include systemic (diabetes mellitus and other metabolic conditions), extrinsic (cardiopulmonary disease, cervical disc, CVA, humerus fractures, Parkinson’s disease), and intrinsic factors (rotator cuff pathologies, biceps tendonitis, calcific tendonitis, AC joint arthritis).

In clinical practice it can be hard to differentiate adhesive capsulitis from other shoulder pathologies and it may be tempting to label any patient with a stiff, painful shoulder as a case of frozen shoulder. Since the physical therapy management of adhesive capsulitis is much different than that of other shoulder pathologies it can be detrimental to the patient if they are misdiagnosed. Therefore, it is important for the clinician to be aware of the ‘hallmarks’ of frozen shoulder and recognize the clinical phases that are specific to this condition  which are discussed below.

Epidemiology /Etiology

Adhesive capsulitis has been reported to affect 2-3% of the general population and up to 30% of people with type II diabetes.  It is more common in women aged 40-60.   While recurrence in the same shoulder is rare, contra-lateral shoulder involvement has been estimated between 20-30%.  Other identified risk factors include  cervical disk disease, iimmobilization of the shoulder, cardiovascular disease, pulmonary disease, hyperthyroidism, and autoimmune diseases. 

Characteristics/Clinical Presentation

Patients may report progressive difficulty with dressing, grooming, and performing overhead activities. Literature describes adhesive capsulitis occuring in three overlapping phases.  The first phase, the painful stage, involves painful shoulder motion and sleep being interrupted.  The second state, the frozen or adhesive stage,  is characterized by reduced pain and loss of joint motion.  During the third stage, the resolution or thawing stage, pain is resolved and motion is gradually returned.    Adhesive capsulitis is thought to be self-limiting with the average recovery taking 3 years, though some authors report 50% of patients have pain or stiffness at 7 years.

Differential Diagnosis

Currently the diagnosis of primary adhesive capsulitis is based on the findings of the patient history and physical examination. No specific clinical test has been reported in the literature, and there remains no gold standard to diagnose adhesive capsulitis . While there is not a set of confirmed diagnostic criteria, a recent study determined a set of clinical identifiers that achieved consensus among 70 experts in the field for the first or early stage of primary (idiopathic) adhesive capsulitis .

Consensus was achieved on 8 clinical identifiers – clustered into 2 discrete domains (pain and movement) as well as an age component .

PAIN

• Strong component of night pain
• Pain with rapid or unguarded movement
• Discomfort lying on the affected shoulder
• Pain easily aggravated by movement

MOVEMENT

• Global loss of active and passive ROM
• Pain at end-range in all directions

Onset > 35 years of age

Other conditions that can present with similar impairments should be included in the clinician’s differential diagnosis. These include, but are not limited to, osteoarthritis, acute calcific bursitis/tendinitis, rotator cuff pathologies, parsonage-Turner syndrome, a locked posterior dislocation, or a proximal humeral fracture  .

Osteoarthritis (OA) vs. Adhesive Capsulitis
Both may have limited abduction and external rotation AROM but with OA, PROM will not be limited. Also, OA will have the most limitations with flexion while this is the motion that is least affected in adhesive capsulitis. Radiography have been used to rule out pathology of osseous structures.

Examination

Currently the diagnosis of primary AD is based on the findings of the patient history and physical examination.

Outcome Measures:
Shoulder Pain and Disability Index (SPADI)
Disability of the Arm, Shoulder and Hand scale (DASH)
American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES)
Simple Shoulder Test (SST)
Penn Shoulder Scale (PSS)
NPRS
VAS
SF-36

In a recent systematic review, the psychometric properties of the SPADI, DASH, ASES and SST were examined. Reliability, construct validity and responsiveness were all found to be favorable for various shoulder pathologies but the review did not address their strength relative to adhesive capsulitis specifically.

Observation of Posture and Positioning

• Scapular tipping of the involved shoulder may be viewable from the posterior and/or lateral views

Upper Quarter Exam (UQE) & Neuro Screen (dermatomes, myotomes, reflexes)

• A full UQE should be performed to rule out cervical spine involvement or any neurological pathologies.

ROM Screen: Active/Passive/Overpressure
Cervical, Thoracic, Shoulder ROMs with OP as well as rib mobility

• Scapular substitution frequently accompanies active shoulder motion.

Resisted Muscle Tests 
Shoulder External Rotation (ER)/ Internal Rotation (IR) / ABduction (ABd) (seated)

• Patients with adhesive capsulitis present with weakness in shoulder ER, IR and ABd relative to the uninvolved side.

Formal ROM: Active/Passive/Overpressure

Shoulder Flex/ABd/ER/IR

• The method of measuring ER and IR ROM in patients with suspected adhesive capsulitis varies in the literature
• Patients with adhesive capsulitis commonly present with ROM restrictions in a capsular pattern where external rotation (ER) is more limited than abduction (ABD) which is more limited than internal rotation (IR) (ER limitations > ABD limitations > IR limitations). A capsular pattern is a proportional motion restriction unique to every joint that indicates irritation of the entire joint. Capsular Pattern for AC: ER is significantly limited when compared to IR and ABD, while ABD and IR were not seen to be different.

Joint Accessory Mobility
Glenohumeral joint

• Anterior 
• Inferior
• Posterior
• Posterior Capsule Stretch

In patients with AC, the anterior and inferior capsule will be the most limited but joint mobility will be restricted in all directions. 

Special Tests for Adhesive Capsulitis
Yang et al investigated the reliability of three function-related tests in patients with shoulder pathologies via a non-experimental study (See Resources): 

Hand-to-neck

• Shoulder flex + abduction + ER
• Similar to ADLs like combing hair, putting on a neclace

''Hand-to-scapula

• Shoulder ext + adduction + IR
• Similar to ADLs like snapping a bra, putting on a jacket, getting into back pocket

Hand-to-opposite scapula

• Shoulder flex + horiz ADDuction

NOTE: All require appropriate elbow, scapulothoracic, and thoracic mobility – make sure to clear this first and keep this in mind during evaluation. If a patient is unable to do the motion it is important to understand that it may be other structures outside of the shoulder joint limiting this motion.

Reliability of the three tests was excellent, ranging from 0.83-0.9. Correlation between the three was moderate (r=0.64 to 0.66).

These functional measures appear to be helpful for their objectivity in measuring shoulder dysfunction. However, even though the test battery is believed to be comprised of movements fundamental to activities of daily living, the direct relationship between these tests and activities of daily living cannot be assumed.

Clinical Identifiers for First Stage of Primary (idiopathic) Adhesive Capsulitis

1) PAIN

• Strong component of night pain
• Pain with rapid or unguarded movement
• Discomfort lying on the affected shoulder
• Pain easily aggravated by movement

2) MOVEMENT

• Global loss of active and passive ROM
• Pain at end-range in all directions

3) Onset > 35 years of age

Irritability Classification
High Irritability

• High Pain (>7/10)
• Consistent night or resting pain
• High disability on DASH, ASES, PSS
• Pain prior to end ROM
• AROM < PROM, secondary to pain

Moderate Irritability

• Moderate pain (4-6/10)
• Intermittent night or resting pain
• Moderate disability on DASH, ASES< PSS
• Pain at end ROM
• AROM similar to PROM

Low Irritability

• Low Pain (<3/10)
• No resting or night pain
• Low disability on DASH, ASES, PSS
• Minimal pain end ROM with OP
• AROM = PROM
  

Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

Research has shown that joint mobilization and exercise increases the likelihood of successful outcomes.  Passive range of motion improved with Matiland grade III or IV mobilizations and posteriorly directed Kaltenborn grade III mobilizations.  Two pairs of interventions:  iontophoresis and phonophoresis and ultrasound and massage, decreased the likelihood of significant improvement by 19-32%. 

Intraarticular corticosteroid injections are another treatment option.  Random, controlled studies show injections with an exercise program improved pain and function scores at 2 weeks, but no difference at 12 weeks.  Therefore, cotricosteroids help initially with pain and function during the first few weeks, but not in the long term. 

Baums et al analyzed 30 patient who had not improved with 6 months of conservative treatment.  Following arthroscopic release, patients demonstrated improved range of motion, functional scores, and decreased pain. 

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources

Description and scoring of the three function-related tests for the first stage of primary adhesive capsulitis. (Note: Adapted from "Reliability of function-related tests in patients with adhesive capsulitis" by Yang et al., 2002, JOSPT, 36, p.573) 

Hand to neck (shoulder flexion and external rotation)*

0   The fingers reach the posteiror median line of the neck with the shoulder in full abduction and external rotation without wrist extension.

1   The fingers reach the median line of the neck but do not have full abduction and/or external rotation.

2   The fingers reach the median line of the neck, but with compensation by adduction in the horizontal plane or by shoulder elevation.

3   The fingers touch the neck.

4   The fingers do not reach the neck.

Hand to scapula (shoulder extension and internal rotation) +

0   The hand reaches behind the trunk to the opposite scapula or 5 cm beneat hit in full internal rotation. The wrist is not laterally deviated.

1   The hand almost reaches the opposite scapula, 6-15 cm beneath it

2   The hand reaches the opposite illiac crest.

3   The hand reaches the buttock.

4   Subject cannot move the hand behind the trunk.

Hand to opposite scapula (shoulder horizontal adduction)§

0   The hand reaches to the spine  of the opposite scapula in full adduction without wrist flexion.

1   The hand reaches to the spine of the opposite scapula in full adduction.

2   The hand passes the midline of the trunk.

3   The hand cannot pass the midline of the trunk.

*This test measures an action essential for daily activities, such as using the arm to reach, pull, or hang an object overhead or using the arm to pick up and drink a cup of water.

+ This test measures an action essential for daily activities, such as using the arm to pull an object out of a back pocket or tasks related to personal care.

§This test measures an action important for daily activities, such as using the arm to reach across the body to get a car's seat belt or using the arm to turn a steering wheel.

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

see adding references tutorial.