Adhesive Capsulitis / Frozen Shoulder - Human & Disease

Adhesive Capsulitis / Frozen Shoulder


 Adhesive Capsulitis / Frozen Shoulder

Capsular tightening at the shoulder, another common disorder, is usually referred to as frozen shoulder or adhesive capsulitis. In most patients seen by physical therapists, no specific cause can be determined for the stiffening. It affects women more often than men, and middle-aged and older persons more often than younger persons. Some so-called idiopathic cases of frozen shoulder probably result from an alteration in scapulohumeral alignment, as occurs with thoracic kyphosis. This is consistent with the fact that women are more frequently affected, because women are also more predisposed to developing thoracic kyphosis than men are. Some believe that this problem is a progression of rotator cuff lesions, in which the inflammatory or degenerative process spreads to include the entire joint capsule, resulting in capsular fibrosis. This may be true in some cases.


Adhesive Capsulitis / Frozen Shoulder Capsular tightening at the shoulder, another common disorder, is usually referred to as frozen shoulder or adhesive capsulitis. In most patients seen by physical therapists, no specific cause can be determined for the stiffening. It affects women more often than men, and middle-aged and older persons more often than younger persons. Some so-called idiopathic cases of frozen shoulder probably result from an alteration in scapulohumeral alignment, as occurs with thoracic kyphosis. This is consistent with the fact that women are more frequently affected, because women are also more predisposed to developing thoracic kyphosis than men are. Some believe that this problem is a progression of rotator cuff lesions, in which the inflammatory or degenerative process spreads to include the entire joint capsule, resulting in capsular fibrosis. This may be true in some cases,
Frozen-Shoulder










there are two major contradictions to this proposal:

- rotator cuff tendinitis affects men and women fairly equally, whereas frozen shoulder is much more common in women.

- persons with a frozen shoulder rarely present with coexistent tendinitis, as evidenced by the absence of pain on resisted movement.

It is commonly thought that these patients stop using the arm because for some reason it is painful, and motion is therefore lost from disuse. this is rarely true; instead, the loss of motion is responsible for the pain. The patient continues to use the arm until the restriction of motion progresses to the extent that it interferes with daily activities. Not until this point is reached does the patient feel much pain or become aware of a problem with the arm.

Adhesive Capsulitis / Frozen Shoulder Capsular tightening at the shoulder, another common disorder, is usually referred to as frozen shoulder or adhesive capsulitis. In most patients seen by physical therapists, no specific cause can be determined for the stiffening. It affects women more often than men, and middle-aged and older persons more often than younger persons. Some so-called idiopathic cases of frozen shoulder probably result from an alteration in scapulohumeral alignment, as occurs with thoracic kyphosis. This is consistent with the fact that women are more frequently affected, because women are also more predisposed to developing thoracic kyphosis than men are. Some believe that this problem is a progression of rotator cuff lesions, in which the inflammatory or degenerative process spreads to include the entire joint capsule, resulting in capsular fibrosis. This may be true in some cases,











¤ The woman first notices that it is difficult to comb her hair and fasten a bra. She may also be awakened at night when rolling onto the affected side.

¤ The man notes difficulty reaching into the hip pocket and combing his hair and may be similarly awakened at night.

Because much shoulder motion can be lost before interfering with daily activities in this age group, these patients invariably do not seek medical help until the shoulder has lost about 90° abduction, 60° flexion, 60° external rotation, and 45° internal rotation. In fact, it is rare for a patient to present with significantly more or significantly less than this amount of movement. Of course, some cases of capsular tightening at the shoulder are associated with particular disease states or conditions.

Adhesive Capsulitis / Frozen Shoulder Capsular tightening at the shoulder, another common disorder, is usually referred to as frozen shoulder or adhesive capsulitis. In most patients seen by physical therapists, no specific cause can be determined for the stiffening. It affects women more often than men, and middle-aged and older persons more often than younger persons. Some so-called idiopathic cases of frozen shoulder probably result from an alteration in scapulohumeral alignment, as occurs with thoracic kyphosis. This is consistent with the fact that women are more frequently affected, because women are also more predisposed to developing thoracic kyphosis than men are. Some believe that this problem is a progression of rotator cuff lesions, in which the inflammatory or degenerative process spreads to include the entire joint capsule, resulting in capsular fibrosis. This may be true in some cases,














Conditions that might result in capsular tightness at the glenohumeral joint include:

1- Degenerative joint disease: This is rare at the shoulder and, if present, is relatively asymptomatic.

2- Rheumatoid arthritis: The smaller joints of the hand and feet are usually affected first. Immobilization. For example, after a fracture of the arm, forearm, or wrist, or dislocation of the shoulder.

3- Reflex sympathetic dystrophy:
(Wrist and Hand Complex). This condition may occur after certain visceral disorders such as a myocardial infarction, or it may occur after trauma, such as a Colles’ fracture. Capsular stiffening of the joints of the hand, wrist, and shoulder is a common component of this syndrome. A frozen shoulder occurring in conjunction with a reflex sympathetic dystrophy is usually more refractory to treatment, probably because of the abnormal pain state that tends to accompany the disorder.

Adhesive Capsulitis / Frozen Shoulder Capsular tightening at the shoulder, another common disorder, is usually referred to as frozen shoulder or adhesive capsulitis. In most patients seen by physical therapists, no specific cause can be determined for the stiffening. It affects women more often than men, and middle-aged and older persons more often than younger persons. Some so-called idiopathic cases of frozen shoulder probably result from an alteration in scapulohumeral alignment, as occurs with thoracic kyphosis. This is consistent with the fact that women are more frequently affected, because women are also more predisposed to developing thoracic kyphosis than men are. Some believe that this problem is a progression of rotator cuff lesions, in which the inflammatory or degenerative process spreads to include the entire joint capsule, resulting in capsular fibrosis. This may be true in some cases.










I. History

A. Site of pain: Lateral brachial region, possibly referred distally into the C5 or C6 segment.

B. Nature of pain: Varying from a constant dull ache to pain felt only on activities involving movement into the restricted ranges. The patient is often awakened at night when rolling onto the painful shoulder.

C. Onset of pain: Very gradual. May be related to minor trauma, immobilization, chest surgery, or myocardial infarction. More commonly, no cause can be cited.

II. Physical Examination

A. Active movements:
 Limitation of motion in a capsular pattern: little glenohumeral movement on abduction, much difficulty, and substitution getting the hand behind the neck. Usually, there is some limitation when flexing the arm or trying to put the hand behind the back.

B. Passive movements: Limitation in a capsular pattern:

external rotation is markedly restricted, abduction is moderately restricted, and flexion and internal rotation are somewhat limited.

1. May be limited by pain with a muscle guarding endfeel (acute)

2. May be limited by stiffness with a capsular end feel (chronic)

C. Joint play: Restrictions of most joint-play movements, especially inferior glide

D. Resisted isometric movements. Strong and painless, unless tendinitis also is present

E. Palpation: Often referred to tenderness over the lateral brachial region. There is often a feeling of increased muscle tone, with induration over the lateral brachial region.

F. Inspection: Often negative. Observe for a surgical scar.

III. Acute vs. Chronic

A. Acute :

1. Pain radiates below the elbow.

2. The patient is awakened by pain at night.

3. On passive movement, the limitation is caused by pain and muscle guarding, rather than stiffness.

B. Chronic :

1. Pain is localized to the lateral brachial region.

2. The patient is not awakened by pain at night.

3. On passive movement, the limitation is caused by capsular stiffness, and pain is felt only when the capsule is stretched.

C. Subacute:
 Some combination of the above findings.

Adhesive Capsulitis / Frozen Shoulder Capsular tightening at the shoulder, another common disorder, is usually referred to as frozen shoulder or adhesive capsulitis. In most patients seen by physical therapists, no specific cause can be determined for the stiffening. It affects women more often than men, and middle-aged and older persons more often than younger persons. Some so-called idiopathic cases of frozen shoulder probably result from an alteration in scapulohumeral alignment, as occurs with thoracic kyphosis. This is consistent with the fact that women are more frequently affected, because women are also more predisposed to developing thoracic kyphosis than men are. Some believe that this problem is a progression of rotator cuff lesions, in which the inflammatory or degenerative process spreads to include the entire joint capsule, resulting in capsular fibrosis. This may be true in some cases.










IV. Management

A. Acute stage :
1. Relief of pain and muscle guarding to allow early, gentle mobilization

a. Ice or superficial heat

b. Grade I or II joint-play oscillations.

2. Maintenance of existing range of motion and efforts to gently begin increasing range of motion.

a. Grade I or II joint-play mobilization. At this stage, it is often best to perform these with the patient lying prone and the arm hanging freely at the side of the plinth. Inferior glide is particularly comfortable for most patients and is usually most helpful in relieving muscle spasms. This is an important movement to perform because the spasm, which is usually present in the acute stage, causes the humerus to assume a superior position in the glenoid cavity, further interfering with normal joint mechanics.

b. Initiation of active assisted range of motion exercises at home, such as auto-mobilization techniques and wand and pendulum exercises.

3. Instruction in isometric strengthening exercises, especially for the rotator cuff muscles. The movements associated with isotonic exercises will usually cause pain and reflex inhibition, thus reducing their effectiveness.

4. Prevention of excessive kyphosis and shoulder girdle protraction. When appropriate, provide instruction in postural awareness for the upper trunk and shoulder girdles such that the patient learns to differentiate proprioceptively between a kyphotic, protracted posture and a relatively upright, retracted position. A system of regular “postural checks” should be incorporated into the patient’s daily activities.

5. Gradual progression of the above program as the condition becomes more chronic.

Adhesive Capsulitis / Frozen Shoulder Capsular tightening at the shoulder, another common disorder, is usually referred to as frozen shoulder or adhesive capsulitis. In most patients seen by physical therapists, no specific cause can be determined for the stiffening. It affects women more often than men, and middle-aged and older persons more often than younger persons. Some so-called idiopathic cases of frozen shoulder probably result from an alteration in scapulohumeral alignment, as occurs with thoracic kyphosis. This is consistent with the fact that women are more frequently affected, because women are also more predisposed to developing thoracic kyphosis than men are. Some believe that this problem is a progression of rotator cuff lesions, in which the inflammatory or degenerative process spreads to include the entire joint capsule, resulting in capsular fibrosis. This may be true in some cases.










B. Chronic stage :

Increase the extensibility of the joint capsule, with special attention to the anteroinferior aspect of the capsule.
1. Ultrasound preceding or accompanying stretching procedures.

2. Specific joint mobilizations, with emphasis on the anteroinferior capsular stretch.


¤ General Guidelines

When using specific joint mobilization techniques in the presence of a chronically tight joint, the primary objective is to stretch the joint capsule. To do so, the more vigorous grade IV techniques must be used. It is usually best, however, to start with grade I or II oscillations in preparation for more intensive stretching. The lower grades of oscillations promote reduced muscle spasm and pain, probably by increasing large fiber sensory input. Perhaps the best technique to use when beginning glenohumeral mobilization is the inferior glide with the arm to the side this technique, especially, seems to induce relaxation. These are also good techniques for relieving the cramping sensation a patient may feel during more vigorous movements.

Before or during capsular stretching procedures, ultrasound can be used to help increase the extensibility of the tissue. For example, perform the anteroinferior capsular stretch while an assistant directs ultrasound to the anteroinferior aspect of the joint. Specific joint mobilization techniques are most effective when used in conjunction with the motions they are intended to restore, such as inferior glide performed simultaneously with abduction or flexion, posterior capsular stretch with internal rotation, and anterior capsular stretch with external rotation. Passive stretching can also be combined with appropriate accessory movements (e.g., flexion with an inferior glide or abduction with an inferior glide).
Instruct the patient in the home range of motion exercises. These are necessary to maintain gains made in treatment and to help increase movement. A major goal of the treatment program is to promote independence in mobilization procedures.

Once about 120° abduction, 140° flexion, and 60° external rotation are achieved, many patients continue to make satisfactory improvement in their range of motion by continuing on a supervised home exercise program.

 From the outset, though, it is difficult for most patients to make substantial gains in range of motion with home exercises alone; skillfully applied passive movement will significantly accelerate improvement in the early phases of treatment. This is probably because, in the relatively acute stage, the reflex muscle spasm that accompanies the active movement of the joint prevents patients from exerting an effective stretch to the joint capsule they simply fight against their own muscles.

Adhesive Capsulitis / Frozen Shoulder Capsular tightening at the shoulder, another common disorder, is usually referred to as frozen shoulder or adhesive capsulitis. In most patients seen by physical therapists, no specific cause can be determined for the stiffening. It affects women more often than men, and middle-aged and older persons more often than younger persons. Some so-called idiopathic cases of frozen shoulder probably result from an alteration in scapulohumeral alignment, as occurs with thoracic kyphosis. This is consistent with the fact that women are more frequently affected, because women are also more predisposed to developing thoracic kyphosis than men are. Some believe that this problem is a progression of rotator cuff lesions, in which the inflammatory or degenerative process spreads to include the entire joint capsule, resulting in capsular fibrosis. This may be true in some cases.














The physiotherapist skilled in the use of passive joint mobilization procedures can localize the stretch to specific portions of the joint capsule and carefully graduate the intensity of the stretch to avoid eliciting protective muscle contraction. Also, the therapist can combine joint-play movements with certain movements of the arm to reduce cartilaginous or bony impingement at the extremes of movement. For example, when moving the arm into abduction, the therapist can passively move the head of the humerus inferiorly to prevent impingement of the greater tubercle against the acromial arch, which would tend to occur from the loss of external rotation and from a loss of inferior glide of the joint.

 By doing so, muscle spasm is reduced and a more effective stretch to the inferior capsule is affected. In fact, until significant gains in external rotation are made, patients should not be instructed to stretch into abduction on their own: attempts to do so may traumatize the subacromial tissues more than stretching the inferior aspect of the joint capsule.

The primary goal of treatment is to restore a painless functional range of movement; regaining full movement of the arm is not always realistic. This is especially true for persons with some degree of increased thoracic kyphosis because the full elevation of the arm involves an extension of the upper thoracic spine. For these patients “normal” elevation is usually about 150° to 160°. The range of motion of the uninvolved shoulder should serve as a guide for setting treatment goals.

In more acute cases of frozen shoulder, the patient’s major complaint is often the inability to get a good night’s sleep: each time he or she rolls onto the involved side, he or she is awakened by pain. The resultant fatigue adds to the patient’s general debilitation. Fortunately, with appropriate management, this is usually the first aspect of the problem to resolve.

In fact, subjective improvement, in the form of a significant reduction in night pain, will usually precede any evidence of objective improvement, such as increased range of motion. one or two sessions of gentle joint-play oscillations, especially into an inferior glide, preceded by superficial heat or ice, are often enough to alleviate nocturnal symptoms. This leads us to speculate whether the night pain may be related more to the fact that the joint is compressed in a position in which the humerus is held into a cephalad malalignment by muscle spasm, rather than being the result of compression of an inflamed joint capsule. At any rate, relaxation of the associated muscle spasm seems to be one of the more important measures in reducing pain in the acute phase. 

In the chronic stage, pain is primarily the result of repeated tensile stresses to the tight joint capsule during daily activities. Treatment is directed primarily at increasing the range of motion, although some restriction of activities may be warranted. For the most part, however, in the chronic stage, encourage the patient to use the arm as much as tolerable to minimize habitual disuse, which can be a factor in perpetuating the disorder.

Some authors claim that adhesive capsulitis is a self-limiting disorder and that spontaneous resolution can be expected in about 12 months. This has not been consistent with our clinical experience. Even if it were true, this should not be a reason for failing to institute active treatment, because with appropriate therapy satisfactory results can be expected within no longer than 3 to 4 months. The only common exception is when a frozen shoulder is part of sympathetic reflex dystrophy. These cases are often refractory to conservative management and may require supplementary measures such as sympathetic blocks or manipulation under anesthesia.

Although in most cases of the frozen shoulder, the prognosis for functional recovery is good, the time frame of recovery is rarely linear. Improvement tends to be characterized by spurts and plateaus. Both the therapist and patient should realize this to avoid undue frustration during periods of limited progress of a frozen shoulder.

Adhesive Capsulitis / Frozen Shoulder Capsular tightening at the shoulder, another common disorder, is usually referred to as frozen shoulder or adhesive capsulitis. In most patients seen by physical therapists, no specific cause can be determined for the stiffening. It affects women more often than men, and middle-aged and older persons more often than younger persons. Some so-called idiopathic cases of frozen shoulder probably result from an alteration in scapulohumeral alignment, as occurs with thoracic kyphosis. This is consistent with the fact that women are more frequently affected, because women are also more predisposed to developing thoracic kyphosis than men are. Some believe that this problem is a progression of rotator cuff lesions, in which the inflammatory or degenerative process spreads to include the entire joint capsule, resulting in capsular fibrosis. This may be true in some cases.



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