Frozen Shoulder: Difference between revisions

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== Differential Diagnosis  ==
== Differential Diagnosis  ==


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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 <ref name="Walmsley" />. 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 <ref name="Walmsley" />.
 
'''Consensus was achieved on 8 clinical identifiers – clustered into 2 discrete domains of pain and movement <ref name="Walmsley" />.'''
 
'''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 &gt; 35 years of age
 
 
 
er 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&nbsp;<ref name="Kline">Kline CM. Adhesive capsulitis: clues and complexities. JAMA Online 2007;2-9.</ref> <ref name="Kelley" />.
 
<u>Osteoarthritis (OA) vs. Adhesive Capsulitis</u><br>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. <br>
 
<u>Bursitis vs. Adhesive Capsulitis</u><br>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. <br>
 
<u>Parsonage-Turner Syndrome (PTS) vs. Adhesive Capsulitis</u><br>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.
 
<br><u>Rotator Cuff (RC) Pathologies vs. Adhesive Capsulitis</u><br>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.
 
<br><u>Posterior Dislocation vs. Adhesive Capsulitis</u><br>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.<br>


== Examination  ==
== Examination  ==

Revision as of 04:42, 15 November 2010

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[edit | edit source]

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Definition/Description[edit | edit source]

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 [1][2][3][4][5]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 [1][2][3][4][5][6]. 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)[2].

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 [1] which are discussed below.

Epidemiology /Etiology[edit | edit source]

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. [6]  While recurrence in the same shoulder is rare, contra-lateral shoulder involvement has been estimated between 20-30%.[3]  Other identified risk factors include  cervical disk disease, iimmobilization of the shoulder, cardiovascular disease, pulmonary disease, hyperthyroidism, and autoimmune diseases.  [7]

Characteristics/Clinical Presentation[edit | edit source]

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.  [7][6]  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. [3]

Differential Diagnosis[edit | edit source]

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 [6]. 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 [6].

Consensus was achieved on 8 clinical identifiers – clustered into 2 discrete domains of pain and movement [6].

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


er 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 [8] [2].

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.

Bursitis vs. Adhesive Capsulitis
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) vs. Adhesive Capsulitis
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 vs. Adhesive Capsulitis
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 vs. Adhesive Capsulitis
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[edit | edit source]


If radiographs are taken, they are typically normal.  [3]

DASH (see Outcome Measures Database)


Medical Management (current best evidence)[edit | edit source]

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Physical Therapy Management (current best evidence)[edit | edit source]

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%.  [7]

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.  [5]

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.  [9]


Key Research[edit | edit source]

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Resources
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Clinical Bottom Line[edit | edit source]

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Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

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  1. 1.0 1.1 1.2 Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ 2005; 331:1453-6.
  2. 2.0 2.1 2.2 2.3 Kelley M, Mcclure P, Leggin B. Frozen shoulder: Evidence and a proposed model guiding rehabilitation. J Orthop Sports Phys Ther 2009;39:135-148.
  3. 3.0 3.1 3.2 3.3 3.4 Brue S et al. Idiopathic adhesive capsulitis of the shoulder: a review. Knee Surg Sports Traumatol Arthrosc. 2007. 15:1048-1054.
  4. 4.0 4.1 Cleland J, Durall CJ. Physical therapy for adhesive capsulitis: Systematic review. Physiotherapy 2002;88:450-457.
  5. 5.0 5.1 5.2 Bal A et al. Effectiveness of Corticosteroid Injection in Adhesive Capsulitis. Clinical Rehabiliation. 2008; 22:503-512.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 Walmsley S, Rivett DA, Osmotherly PG. Adhesive capsulitis: Establishing consensus on clinical identifiers for stage 1 using the delphi technique. Phys Ther 2009;89:906-917.
  7. 7.0 7.1 7.2 Jewell DV et al. Interventions Associated With an Increased or Decreased Likelihood of Pain Reduction and Improved Function in Patients With Adhesive Capsulitis: A Retrospective Cohort Study. Physical Therapy. May, 2009. 89(5): 419-428.
  8. Kline CM. Adhesive capsulitis: clues and complexities. JAMA Online 2007;2-9.
  9. Baums MH et al. Functional Outcome and General Health Status in Patients after Arthroscopic Release in Adhesive Capsulitis. Knee Surg Sports Traumatol Arthrosc. 2007; 15:638-644.