Adhesive Capsulitis often referred to as frozen shoulder is characterized by initially painful and later progressive restricted active and passive glenohumeral joint range of motion with spontaneous complete not non-compete recovery over a varied period of time.
The inflammatory condition that causes fibrosis of glenohumeral joint capsule accompanied by gradually progressive stiffness and restriction of range of motion (typically external rotation).
Causes: Causes remain unclear.
· Primary – onset is idiopathic.
· Secondary – results from a known cause or a surgical event.
· Diabetes mellitus.
· Thyroid disorder
· Dupuytren disease
· Shoulder injury
· Complex regional pain syndrome
· Onset with a progressive increase in pain.
· Gradual decrease in active and passive range of motion.
· Difficulty with grooming, performing overhead activities, dressing, and particularly fastening items behind the back.
Adhesive Capsulitis is a self-limiting disease with symptom resolution as early as 6 months to 11 years.
Adhesive Capsulitis progresses through three overlapping clinical phases;
- Acute/freezing/painful phase: gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and pain at night with sleep interruption which may last anywhere from 3-9 months.
- Adhesive/frozen/stiffening pain: Pain starts to subside, progressive loss of glenohumeral motion in capsular pattern. Pain is apparent only at extremes of movement. This phase may occur at around 4 months and last till about 12 months.
- Resolution/thawing phase: Spontaneous, progressive improvement in functional range of motion which can last anywhere from 1 to 3.5 years.
Ø Listen carefully to the patient’s past medical history (PMHx), this may well rule out red flags and guide the shoulder examination.
Ø History of presenting condition (Hx PC).
Ø Pain distribution and severity Strong component of night pain, pain with rapid or unguarded movement, discomfort lying on the affected shoulder, pain easily aggravated by movement
Ø Aggravating activities - limited reaching, particularly during overhead (e.g., hanging clothes) or to-the-side (e.g., fasten one's seat belt) activities. Patients also suffer from restricted shoulder rotations, resulting in difficulties in personal hygiene, clothing and brushing their hair. Another common concomitant condition with frozen shoulder is neck pain, mostly derived from overuse of cervical muscles to compensate the loss of shoulder motion.
Observation of posture and positioning:
Ø A full upper quarter exam (UQE) should be performed to rule out cervical spine involvement and Any neurological pathologies.
Ø Cervical, thoracic, shoulder range if motions (ROM) with overpressure as well as rib mobility should be performed.
Ø Shoulder external rotation (ER), internal rotation (IR), abduction (ABd) (seated) should be performed.
Ø Shoulder shrug sign- inability to lift the arm to 90° abduction without elevating the whole scapula or shoulder gridle.
Physical therapy management:
Techniques for initial phase, painful and freezing. – pain relief and exclusion of other potential causes of frozen shoulder is the focus during this phase
o Very gentle shoulder mobilization
o Dry needling
o Kinesiology taping
o TENS machine
o Hot pack
Second phase- decreased range of motion.
o Gentle and specific shoulder mobilization
o Dry needling
o Mobilization with movement (MWM) style techniques. – most effective and more effective than stretching exercises alone.
Third phase – resolution.
o Exercise progression including strengthening exercises to control and manage increased range of motion.
o Progressed primarily by increasing stretch frequency and duration, whilst maintaining the same intensity, as tolerated by the patient. The stretch can be held for longer periods and the sessions per day can be increased. As the patient’s irritability level reduces, more intense stretching and exercises using a device, such as a pulley, can be performed to influence tissue remodeling.
Various Interventions have been researched that address the treatment of synovitis and inflammation and modify the capsular contractions such as oral medication, corticosteroids injection, distention, manipulation and surgery. Even though many of these treatments have shown significant benefits, it is suggested that the primary treatment for adhesive capsulitis should be based around physical therapy and anti-inflammatory measures.
Kolby and Kissner, therupatic exercise, ed.7
Laxmi Narayan textbook of therupatic exercises ,ed1,2005