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

Primary adhesive capsulitis is due to an unknown cause while secondary adhesive capsulitis results from a known cause or surgical event. It is more prevalent in women, individuals 40-65 years old, and in the diabetic population, with an occurrence rate of approximately 2-5% in the general population , and 10-20% of the diabetic population. Once the patient has adhesive capsulitis they have a 5-34% increased risk of having it in the contralateral shoulder, and bilateral occurrence occurs approximately 14% of the time.

The etiology of adhesive capsulitis remains unclear. Other associated risk factors in addition to the ones mentioned above include: trauma, prolonged immobilization, thyroid disease, stroke, myocardial infarcts, and presence of autoimmune disease.

The disease process affects the anteriosuperior joint capsule and the coracohumeral ligament. Arthroscopy shows that patients have a small joint with loss of the axillary fold and tight anterior capsule, mild or moderate synovitis, and no adhesions. Also, contracture of the rotator cuff interval has been seen in adhesive capsulitis patients, and greatly contributes to the decreased range of motion seen in this patient population.

There is continued disagreement about whether the underlying pathology is an inflammatory condition, fibrosing condition, or an algoneurodystrophic process. Evidence does show synovial inflammation followed by reactive capsular fibrosis, in which type I and III collagen is laid down with subsequent tissue contraction. Elevated levels of serum cytokines have been noted and facilitate tissue repair and remodeling during inflammatory processes. In primary and some secondary cases of adhesive capsulitis cytokines have shown to be involved in the cellular mechanism that leads to sustained inflammation and fibrosis. It is proposed that there is an imbalance between aggressive fibrosis and a loss of normal collagenous remodeling, which can lead to stiffening of the capsule and ligamentous structures.

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 .

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

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  . 

Differential Diagnosis of Adhesive Capsulitis

Osteoarthritis (OA)

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.

Bursitis

Bursitis presents very similarly to adhesive capsulitis, especially compared to the early phases of frozen shoulder. Patients with bursitis will present with a non-traumatic onset of severe pain with most motions being painful. A main difference will be the amount of PROM achieved with adhesive capsulitis being extremely limited and painful while bursitis will, while still painful, have larger ranges.

Parsonage-Turner Syndrome (PTS)

PTS occurs due to inflammation of the brachial plexus. Patients will present without a history of trauma and with painful restrictions of all motions. The pain with PTS usually subsides much quicker than with adhesive capsulitis, and patients eventually display neurological problems (atrophy of muscles or weakness) that are seen several weeks after initial onset of pain.

Rotator Cuff (RC) Pathologies

The primary way to distinguish RC pathologies from adhesive capsulitis is to examine the specific ROM restrictions. Adhesive capsulitis presents with restrictions in the capsular pattern while RC involvement typically does not. RC tendinopathy may present similarly to the first stage of adhesive capsulitis because there is limited loss of external rotation and strength tests may be normal. MRI and ultrasonography can be used to identify soft tissue abnormalities of the soft tissue and labrum.

Posterior Dislocation

A posteriorly dislocated shoulder can present with shoulder pain and limited ROM but, unlike adhesive capsulitis, started with a specific traumatic event. If the patient is unable to fully supinate the arm while flexing the shoulder, the clinician should suspect a posterior dislocation.

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)

No Definitive Treatment

     The definitive treatment for adhesive capsulitis remains unclear even though multiple interventions have been studied. Previously published prospective studies of effective treatment have demonstrated conflicting results for improving shoulder range of motion in patients with this condition . Non-operative interventions include patient education, modalities, stretching exercises, and joint mobilization , . Levine et al. reported that 89.5% of ninety – eight patients with frozen shoulder responded with non-operative management.  Reviewed studies suggest that many patients have benefited from physical therapy and have reduced symptoms, increased mobility, and/or functional improvement . However, A Cochrane by Green states that there is, “no evidence that physiotherapy alone is of benefit for adhesive capsulitis.”

Importance of Patient Education
     For the treatment of adhesive capsulitis, patient education is important in order to help reduce frustration and encourage compliance. It is important to emphasize that although full range of motion may never be recovered, the condition will spontaneously resolve and stiffness will greatly reduce with time. Treatment should be tailored to the stage of the disease . It is also helpful to give quality instructions to the patient and create an appropriate home exercise program that is easy to comply with because daily exercise is effective in relieving symptoms .

 
Modalities
     Modalities, such as hot packs, can be applied before or during treatment. Moist heat used in conjunction with stretching can help to improve muscle extensibility and range of motion by reducing muscle viscosity and neuromuscular – mediated relaxation . In the randomized study by Bal, patients improved with combined therapy which included hot and cold packs applied before and after shoulder exercises were performed . However, a study by Jewell et al., claimed that ultrasound, massage, iontophoresis, and phonophoresis reduced the odds of improved outcomes for patients with adhesive capsulitis. A Cochrane Review by Green states, “There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis.”

Initial Phase: Painful, Freezing 
      Pain relief should be the focus of the initial phase, also known as the Painful, Freezing Phase. During this time, any activities that cause pain should be avoided, as supported by a prospective study by Dierks et al. In this study, better results were found in patients who performed pain-free exercise, rather than intensive physical therapy. In patients with high irritability, range of motion exercises performed with low intensity and short duration can alter joint receptor input, reduce pain, and decrease muscle guarding. Stretches may be held from one to five seconds at a pain – free range, two to three times a day. A pulley may be used to assist range of motion and stretch, depending on the patient’s ability to tolerate the exercise. Core exercises include pendulum exercise, passive supine forward elevation, passive external rotation with the arm in approximately forty degrees of abduction in the plane of the scapula, and active assisted range of motion in extension, horizontal adduction, and internal rotation . In the case of adhesive capsulitis, physical therapy can also be a complement to other therapies, especially to improve the range of motion of the shoulder . Steroid injections, when combined with physical therapy, have been found to be more effective than physical therapy alone for patients with adhesive capsulitis, according to a randomized control trial by Carette et al. Also, suprascapular nerve blocks were found to be beneficial in terms of pain relief, but not movement . Green et al., carried out a systematic review in which the authors concluded that no evidence exists that physical therapy alone, without concurrent interventions, such as corticosteroid injections, is beneficial for treatment of adhesive capsulitis. In a randomized study by Bal et al., this point was further evidenced in 2007 through results that demonstrated fast relief of pain and improvement in disability in short term when intraarticular corticosteroid therapy was used concominantly with exercise. Exercise included isometric strengthening in all ranges once motion was reached in 90% of normal ranges, theraband exercises in all planes, scapular stabilization exercises, and later, advanced muscular strengthening with dumbbells . In a single-patient case-report by Ruiz, positional stretching of the coracohumeral ligament was performed for a patient in the first phase of adhesive capsulitis. The patient Disabilities of Arm Shoulder and Hand (DASH) scores improved from 65 to 36 and Shoulder Pain and Disability Index (SPADI) scores improved from 72 to 8 and passive external rotation from 20 degrees to 71 degrees. The stretches performed focused on providing positional low load and prolonged stretch to the CHL and the area of the rotator interval capsule following anatomical fiber orientation. The rationale behind this was to produce tissue remodeling through gentle and prolonged tensile stress on the restricting tissues. While a cause and effect relationship cannot be inferred from a single case, this report may help with further investigation regarding therapeutic strategies to improve function and reduce loss of range of motion in the shoulder and the role that the CHL plays in this .

Second Phase: Adhesive 
     During the adhesive phase, more aggressive stretching exercises should be the focus of treatment, in order to improve range of motion. The patient should perform low load, prolonged stretches in order to produce plastic elongation of tissues and avoid high load, brief stretches, which would produce high tensile resistance . A prospective study by Griggs et al., demonstrated success of a non – operative treatment through a four – direction shoulder stretching exercise program in which 90% of the patients reported a satisfactory outcome . During the second phase of treatment, movement with mobilization and end range mobilization have shown to be successful, according to a randomized multiple treatment trial by Yang et al. In this trial, during the second phase of adhesive capsulitis, the patients undergoing mobilization with movement and end range mobilization had statistically significant improvements in the Flexi – Level Scale of Shoulder Function (FLEX-SF), arm elevation, scapulohumeral rhythm, humeral external rotation, and humeral internal rotation. Also, mobilization with movement corrected scapulohumeral rhythm significantly better than end range mobilization did. The goal for end range mobilization was not only to restore joint play, but also to stretch contracted periarticular structures. The goal for mobilization with movement was to restore pain-free motion to the joints that have painful limitation of range of movement . A controlled, cohort study, performed by Gaspar, showed that physical therapy paired with dynamic splinting worked best for improving active, external rotation in patients with adhesive capsulitis, rather than physical therapy alone or dynamic splinting alone. The patients in this group of combined treatments received physical therapy twice weekly and Shoulder Dynasplint System (SDS) for daily end-range stretching. The physical therapy was standardized, based on the protocols of Vermeulen, Hsu, and Mulligan. Methods for this treatment include moist heat, patient education and re-evaluation of symptoms, joint mobilization (limited to progressive end-range joint mobilization), passive range of motion, active range of motion and PNF, and therapeutic exercise. SDS was worn twice each day for seven days per week and was set at #1 for the first week in order to allow the patient to accommodate to the stretching. After accommodation, the setting was increased to #2, which equals three foot lbs of force. The progression of the stretch as well as the adjustment for pain or soreness was standardized, and instructions were given to the patient to follow accordingly. Patients were instructed to increase the duration in the SDS unit for 20 – 30 minutes twice each day (with the intention to stretch 60 minutes each day .

Third Phase: Resolution 
     During stage three, also known as the Resolution Phase, tissue stress is progressed primarily by increasing stretch frequency and duration, while maintaining the same intensity, as the patient is able to tolerate. The stretch can be held for longer periods, and the sessions per day can be increased. As the patient’s irritability level becomes low, more intense stretching and exercises using a device, such as a pulley, can be performed to assist tissue remodeling influence .

When Functional Disability Persists 
     If functional disability persists despite non-operative treatment, for six months, manipulation under anesthesia can be performed and usually results in improvement in shoulder range of motion and function within three months. If this procedure fails to release the capsule, arthroscopic release of the capsule has been shown to allow a more controlled release of the contracted capsule.

Helpful Manual Techniques 
     High – grade mobilization techniques (HGMT) have been shown to be helpful for improving range of motion in patients with adhesive capsulitis for at least three months. In a study by Vermeulen et al., statistically significant greater change scores were found in the HGMT group for passive abduction (at the time of three and twelve months), and for active and passive external rotation (at twelve months) when compared with low – grade mobilization techniques. A statistically significant difference in trend between both groups over the total twelve month follow up period was found for external rotation, SRQ, and SDQ with greater change scores in the HGMT group. It can then be concluded that high-grade mobilization techniques appear to be more effective for increasing joint mobility and reducing disability. Gliding, as well as the distraction of the humeral head, was performed in order to influence the anterior, middle, and posterior parts of the joint capsule. Mobilization techniques were performed at greater elevation and abduction angles if glenohumeral joint range of motion increased during treatment. These techniques were performed at grades III and IV to the subjects’ tolerance with the intention of “treating the stiffness.” Mechanical changes that occur as a result of these mobilizations may include the break- up of adhesions, realignment of collagen, or increased fiber glide when specific movements stress certain parts of the capsular tissue. Also, mobilization techniques were intended to increase joint mobility by inducing changes in synovial fluid formation. Future studies are needed to investigate whether HGMTs applied during earlier stages of adhesive capsulitis are as effective as in this particular study by Vermeulen . Another study performed by Johnson et al, showed that joint mobilizations, in particular posterior glenohumeral glides, can help decrease deficits in external rotation, moreso than anterior glenohumeral glides. In a randomized clinical trial, Johnson proved this treatment effective, as a significant difference was shown between the two groups (anterior glide treatment vs. posterior glide treatment) by the third treatment session. The individuals in the anterior mobilization treatment group had a mean improvement in external rotation range of motion of three degrees (SD 10.8 degrees) , whereas the individuals in the posterior mobilization treatment group had a mean improvement of 31.3 degrees (7.4 degrees). Both groups had a significant decrease in pain, but there was more improvement in external rotation range of motion in the group with the posterior mobilization treatment . Another randomized controlled trial, performed by Zimmerman et al., found results consistent with this trial by Johnson, in which posteriorly directed joint mobilizations showed greater improvements in external rotation that anteriorly directed joint mobilizations . Yang et al. performed a multiple treatment trial using combinations of end-range mobilization, mid-range mobilization, and mobilization with motion in patients with adhesive capsulitis. Improved motion and function was found at 12 weeks with end – range mobilization. It was concluded that end range mobilization was more effective than mid-range mobilization in increasing motion and functional mobility . The results in a study by Jewell et al., are also consistent with these randomized control trials and studies that have demonstrated the beneficial effects of joint mobilization and exercise for patients with adhesive capsulitis .

Rationale Behind Stretching
     Research regarding connective tissue stretch duration and intensity has produced three findings. First, high intensity, short duration stretching aids the elastic response, while low intensity, prolonged duration stretching aids the plastic response. Secondly, a direct correlation exists between the resulting proportion of plastic, permanent elongation and the duration of a stretch. Lastly, a direct correlation exists between the degree of either trauma or weakening of the stretched tissues and the intensity of a stretch. Mc Clure, et al., stated that the maximum TERT (Total End Range Time) or the total amount of time the joint is held at near end range position, will be different for each person, and is often affected by personal circumstances such as a job or other responsibilities that may prevent a patient from increasing TERT .

Progression
     Manual techniques and exercise should only be progressed as the patient’s irritability reduces. Patient response to treatment should be based on their pain relief, improved satisfaction, and functional gains, rather than restoration of range of motion. Usually, patients are discharged when significant pain reduction is reached, a plateau of motion gains are noticed for a period of time, and after improved functional motion and satisfaction have reached their peak . Progression for stretching via dynamic splinting is also based on patient tolerance, as well. In the controlled cohort study by Gaspar if the patients experienced discomfort or stiffness lasting more than an hour after the splint was removed, the duration of treatment was reduced for the next two scheduled stretching sessions. After the patient was able to tolerate stretching for a total of 60 minutes (30 minutes twice a day), the patient then increased the tension every two weeks based on tolerance, without discomfort lasting more than one hour following every stretching session .

What We Need
     “Despite extensive research, we still need prospective randomized studies comparing different treatments to formulate precise guidelines about the diagnosis and treatment of idiopathic adhesive capsulitis . The lack of validity, poor standardization of terminology, methodology, and outcome measures in the investigations undermines clinical application. Therefore, more rigorous investigations are needed to compare the cost and effectiveness of physical therapy interventions .

Example of a Physical Therapy Protocol for Adhesive Capsulitis  

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Phase I:

File:Kelley Figure 2 flex ER ext HEP.JPG

Figure 2. Taken from "Evidence and a Proprosed Model for Guiding Rehabilitation by Kelley M, et al. J Orthop Sports Ther 2009; 39: 135 - 148

Note: (First two images taken from "Evidence and a Proprosed Model for Guiding Rehabilitation by Kelley M, et al. J Orthop Sports Ther 2009; 39: 135 - 148)

1. Patient education:

•emphasize full ROM may never be recovered
•spontaneous resolution & reduction of stiffness
•instructions for HEP
•avoid painful activity/activity modification

2. Upper body cycle ergometer: 50 r.p.m, 8 minute warm - up

3. Modalities: 10 - 15 minutes, before, during, or after exercise

•moist heat
•cold pack

4. ROM exercise/stretches: low intensity, short duration, 1-5 seconds, 2-3 times per day, pain-free, passive, AAROM

•pendulums (1 min clockwise, 1 min counter-clockwise)
•internal rotation in standing
•horizontal adduction in standing
•pulley for elevation in sitting or standing
•foward flexion in supine using own hand
•external rotation using pipe/stick in supine
•extension in standing using pipe/stick in supine

File:Kelley Figure 3 IR horizADD pulley HEP.JPG

Figure 3. Taken from "Evidence and a Proprosed Model for Guiding Rehabilitation by Kelley M, et al. J Orthop Sports Ther 2009; 39: 135 - 148

 

5. Manual Techniques:

•Low - grade mobilization (Grade I or II)
•Positional stretching of CHL: 5 minutes-> progress to 15 minutes

6. Strengthening:

•Isometric in all planes, 5 second holds, 1 set of 10 each direction, against wall

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Phase II:

1. Patient education:

•moderate irritability
•activity modifications/basic functional activities

2. Upper body cycle ergometer: 50 r.p.m, 8 minute - warm up

3. Modalities: 10 - 15 minutes, before, during, or after exercise

•moist heat
•cold pack

4. ROM exercise/stretches: 5 - 15 seconds, passive AAROM to AROM, low load, prolonged

File:Ruiz CHL positional stretch.JPG

Figure 1: CHL Stretch. Taken from " Positional Stretching of the Coracohumeral Ligament on a Patient with Adhesive Capsulitis: A Case Report by Ruiz et al, Journal of Manipulative & Manual Therapy Vol 17: No. 1: 58-63

•Same as in Phase I, but increase duration and length of stretch

 Note: (Image to right taken from " Positional Stretching of the Coracohumeral Ligament on a Patient with Adhesive Capsulitis: A Case Report by Ruiz et al, Journal of Manipulative & Manual Therapy Vol 17: No. 1: 58-63)

5. Manual Techniques:

•Same as Phase I for abd and flexion, instead End-Range in varying degrees of elevation and rotation, 10 - 15 repetitions
•Mobilization with Movement 3 sets of 10 repetitions with 1 minute rest in between
•Last 3 minutes, passive PNF if needed to increase ROM
•Low - to - High Grade Mobilizations

6. Strengthening:

•Theraband: 5 directions, 3 sets of 12 reps, progress with colors of band

File:Anterior Mobilization - Johnson.jpeg

Figure 2A/2B: Anterior Mobilization. Taken from "The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with adhesive capsulitis," by Johnson AJ, et al. 2000 J Orthop Phys Ther 37, pp88-89

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Note: Two Images to the right (Figures 2A, 2B, 3A, 3B taken from "The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with adhesive capsulitis," by Johnson AJ, et al. 2000 J Orthop Phys Ther 37, pp88-89)

Phase III:
1. Patient education:

•increase activities/high demand activities
•pain decreased

2. ROM exercises/stretches:

•same as phase II, but increase duration, past end - range
•end range/lower pressure, increased duration, cyclic loading
•can use stick or cane in standing over table for prolonged elevation & external

File:Post mob johnson.JPG

Figure 3A/3B: Posterior Mobilization. Taken from "The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with adhesive capsulitis," by Johnson AJ, et al. 2000 J Orthop Phys Ther 37, pp88-89

rotation

3. Manual Techniques:

•distraction, posterior glides > anterior glides (perform before HGMT) 3 sets of 30 seconds
•High Grade Mobilization/Sustained (HGMT)
•Grades III & IV
•abduction and external rotation
•End-range posterior mobilizations hold 1 minute x 15 times
•last 3 minutes passive PNF, if needed to increase ROM

4. Strengthen:

•Low - to - high resistance end range dumbell in sitting: flexion, abduction, extension 1 - 2 lbs to begin with, 2 - 3 sets of 10
•sidelying dumbells IR, ER 3 sets of 10 - 12 (1 - 2 lbs)

Figure 4. Taken from "Evidence and a Proprosed Model for Guiding Rehabilitation by Kelley M, et al. J Orthop Sports Ther 2009; 39: 135 - 148

Note: (Image to the right, Figure 4 taken from "Evidence and a Proprosed Model for Guiding Rehabilitation by Kelley M, et al. J Orthop Sports Ther 2009; 39: 135 - 148)

Note: (Image Below, Figure 1 Dynasplint ) 

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Examples of Physical Therapy Exercises or Techniques that can be Used for Home Exercise Program

•Forward flexion performed in supine
•External rotation performed in supine using pipe/stick
•Extension performed in standing using pipe/stick
•Internal rotation performed in standing
•Horizontal adduction performed in standing
•Pulley for elevation performed in sitting/standing
•Pendulums (clockwise/counter-clockwise)
•Theraband (5-way)
•CHL Stretching Technique with cold pack over anterolateral shoulder with goal of up to no more than 20 minutes per day, twice a day
•Dynasplint (20 - 30 minutes, twice a day) -->(Progress to a total of 60 minutes per day)

File:Gaspar FIgure 1 Dynasplint.JPG

Figure 1. Taken from "Adhesive capsulitis and dynamic splinting: A controlled, cohort study. by Gaspar P, et al. BMC Musculoskeletal Disorders 2009; 10:111

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

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