Frozen Shoulder: Difference between revisions

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== Definition/Description ==
== Search Strategy ==


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<ref name="Dias">Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ 2005; 331:1453-6.</ref><ref name="Kelley">Kelley M, Mcclure P, Leggin B. Frozen shoulder: Evidence and a proposed model guiding rehabilitation. J Orthop Sports Phys Ther 2009;39:135-148.</ref><ref name="Brue">Brue S et al. Idiopathic adhesive capsulitis of the shoulder: a review. Knee Surg Sports Traumatol Arthrosc. 2007. 15:1048-1054.</ref><ref name="Cleland">Cleland J, Durall CJ. Physical therapy for adhesive capsulitis: Systematic review. Physiotherapy 2002;88:450-457.</ref><ref name="Bal" /><ref name="Bussieres">Bussieres AE, Peterson C, Taylor JA. Diagnostic imaging guideline for musculoskeletal complaints in adults - an evidence based approach: Part 2 - upper extremity disorders. J Manipulative Physiol Ther 2008;31:2-32.</ref> most notably shoulder&nbsp;abduction and external rotation.  
To search for information about adhesive capsulitis, medical databases, such as Pubmed and PEDro, were used. Keywords I used to find information are&nbsp;adhesive capsulitis, frozen shoulder, treatment AND adhesive capsulitis, exercises AND adhesive capsulitis. To improve the strategy I used the limits on Pubmed: 5 years (published in the last), English (languages), humans (species). The amount of articles is 303.  


Adhesive capsulitis, commonly referred to as frozen shoulder, is associated with synovitis and capsular contracture of the shoulder joint and can be classified as either primary or secondary. <ref name="Dias" /><ref name="Kelley" /><ref name="Brue" /><ref name="Cleland" /><ref name="Bal" /><ref name="Walmsley">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.</ref>&nbsp;In clinical practice it can be hard to differentiate adhesive capsulitis from other shoulder pathologies.<ref name="Dias" /> 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&nbsp;<ref name="Dias" /> which are discussed below. <br>
== Definition/Description  ==


== Epidemiology /Etiology  ==
Adhesive capsulitis, or frozen shoulder, is a condtion in which the capsule of the glenohumeral joint is inflamed. It is characterized by a painful, gradual loss of both active and passive glenohumeral motion, resulting from progressive fibrosis and contracture of the glenohumeral joint capsule.&nbsp;<ref name="Review" />&nbsp;<ref name="Walm" />&nbsp;Contracture is defined as shortening of connective tissue (ligaments, tendons, and cartilage) and caused by excessive arthrofibrosis, immobilization, inactivation and adhesions.<ref name="Gaspar">Gaspar PD, Willis FB, Adhesive capsulitis and dynamic splinting: a controlled, cohort study, BMC Musculoskelet Disorders, 2009 Sep 7;10:111. Level of evidence B.</ref>&nbsp;


[[Image:Glenohumeral joint.png|thumb|right|300px|Glenohumeral Joint]]
Adhesive capsulitis is described as being either primary or secondary. Primary, or idiopathic, adhesive capsulitis is due to an unknown cause, whereas secondary adhesive capsulitis results from a known cause or surgical event. <ref>Sam W. Wiesel, John N. Delahay, Essentials of Orthopedic Surgery. 4th Edition, 2010, Springer Science+Business Media LLC, NY (USA).</ref><br>


Although the etiology remains unclear,&nbsp;adhesive capsulitis can be classified as primary or secondary. Frozen shoulder is considered primary if the onset is idiopathic while secondary results from a known cause or surgical event.<ref name="Walmsley" /> Three subcategories of secondary frozen shoulder include systemic ([[Diabetes|diabetes mellitus]] and other metabolic conditions), extrinsic ([[Cardiopumlonary|cardiopulmonary]] disease, cervical disc, [[Stroke|CVA]], humerus fractures, [[Parkinsons Disease|Parkinson’s disease]]), and intrinsic factors ([[Rotator Cuff|rotator cuff pathologies]], [[Biceps Tendonitis|biceps tendonitis]], [[Calcific tendonitis of the shoulder|calcific tendonitis]], [[Acromioclavicular Joint|AC joint]] arthritis).<ref name="Kelley" />&nbsp;
== Clinically Relevant Anatomy  ==


Adhesive capsulitis is often 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, <ref name="Bal" /><ref name="Kelley" /><ref name="Gaspar">Gaspar P, Willis B. Adhesive capsulitis and dynamic splinting: a controlled, cohort study. BMC Musculoskeletal Disorders 2009;10:111.</ref><ref name="Boyles">Boyles RE, Flynn TW, Whitman JM. Manipulation following regional intrascalene anesthetic block for shoulder adhesive capsulitis: A case series. Man Ther 2005:10;164-171.</ref><ref name="Cleland" /><ref name="Vermeulen" /> and 10-20% of the diabetic population.<ref name="Boyles" /><ref name="Vermeulen" />&nbsp;If&nbsp;an individual has&nbsp;adhesive capsulitis they have a 5-34% chance of having it in the contralateral shoulder at some point in time. Simulatneous bilateral involvement has been found to occur approximately 14% of the time.<ref name="Kelley" />&nbsp;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.<ref name="Bal" /><ref name="Jewell">Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: A retrospective cohort study. Phys Ther 2009;89:419-429.</ref>
Contracture of the rotator cuff interval (RCI) is prevalent. The RCI forms the triangular-shaped tissue between the anterior supraspinatus tendon edge and upper subscapularis border, and includes the superior glenohumeral ligament and the coracohumeral ligament.  


The disease process affects the anteriosuperior joint capsule, axillary recess,&nbsp;and the coracohumeral ligament. It has been shown through arthroscopy that patients tend to have a small joint with loss of the axillary fold, tight anterior capsule and mild or moderate synovitis but no actual&nbsp;adhesions.<ref name="Dias" /><ref name="Vermeulen" />&nbsp;Contracture of the rotator cuff interval has also been seen in adhesive capsulitis patients, and greatly contributes to the decreased range of motion seen in this population.<ref name="Kelley" />  
Significant subacromial scarring, loss of the subscapular recess, and inflammation of the long head of the biceps tendon and its synovial sheath is noticed in patients with frozen shoulder. <ref name="Kelley" /><br>  


There is continued disagreement about whether the underlying pathology is an inflammatory condition, fibrosing condition, or an algoneurodystrophic process. Evidence suggests there is synovial inflammation followed by capsular fibrosis, in which type I and III collagen is laid down with subsequent tissue contraction.<ref name="Dias" /> 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.<ref name="Kelley" />
== Epidemiology /Etiology ==
 
== Characteristics/Clinical Presentation  ==
 
Patients presenting with adhesive capsulitis will often&nbsp;report an insidious onset with a progressive increase in pain, and gradual decrease in active and passive range of motion.<ref name="Kelley" /><ref name="Gaspar" /> Patients&nbsp;frequently have difficulty with grooming, performing overhead activities, dressing, and particularly fastening items behind the back.<ref name="Jewell" /><ref name="Cleland" /> Adhesive capsulitis is considered to be a self-limiting disease with sources stating symptom resolution&nbsp;as early as 6 months up to 11 years. Unfortunately&nbsp;symptoms may never fully subside in many patients.<ref name="Jewell" /><ref name="Kelley" /><ref name="Yang JI" /><ref name="Kline">Kline CM. Adhesive capsulitis: clues and complexities. JAMA Online 2007;2-9.</ref><ref name="Bal" /><ref name="Gaspar" /><ref name="Blanchard">Blanchard V, Barr S, Cerisola FL. The effectivemess of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitits: A systematic review. Physiotherapy 2010; 96: 95-107.</ref><ref name="Brue" /><ref name="Cleland" />
 
The literature reports that adhesive capsulitis progresses through three overlapping clinical phases:<ref name="Dias" /><ref name="Cleland" /><ref name="Kline" /><ref name="Jewell" /><ref name="Walmsley" />
 
*'''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 phase''': 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 til about 12 months.
*'''Resolution/thawing phase''': Spontaneous, progressive improvement in functional range of motion which can last anywhere from 1 to 3.5 years.
 
== Differential Diagnosis  ==
 
Some conditions can present with similar impairments and 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" />
 
{| width="650" cellspacing="1" cellpadding="1" border="3" align="center"
|+ '''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.
|-
| &nbsp;
|-
| ''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.
|-
| &nbsp;
|-
| ''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.
|-
| &nbsp;
|-
| ''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.
|-
| &nbsp;
|-
| ''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.
|}
 
<u></u>
 
== Examination ==


Currently the diagnosis of primary&nbsp;adhesive capsulitis&nbsp;is based on the findings of the patient history and physical examination.<ref name="Walmsley" />&nbsp;  
Adhesive capsulitis occurs in 2% to 5% of the population. The majority of patients are female, and especially between the ages of 40 to 60 years.&nbsp;<ref name="Review" /><ref name="Walm">Walmsley S, Rivett DA, Osmotherly PG., Adhesive capsulitis: establishing consensus on clinical identifiers for stage 1 using the DELPHI technique., Phys Ther. 2009 Sep;89(9):906-17. Epub 2009 Jul 9. Level of evidence B.</ref>&nbsp;The non-dominant hand is more frequently involved, and about 20% to 30% of those affected will develop the condition in the opposite shoulder.&nbsp;  


The following outcome measures have been used in studies researching adhesive capsulitis.  
The causes remain unclear. Twenty percent to 30% of patients will report a history of minor trauma to the shoulder, but there is no further evidence that this is a posttraumatic condition. Others develop this condition due to an unknown cause.  


*Shoulder Pain and Disability Index (SPADI)
The development of adhesive capsulitis has been associated with:
*Disability of the Arm, Shoulder and Hand scale ([[DASH Outcome Measure|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.<ref name="Roy">Roy J, MacDermid J, Woodhouse L. Measuring shoulder function: A systematic review of four questionnaires. Arthritis Rheum 2009;61(5):623-632.</ref>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.
- diabetes mellitus


==== OBSERVATION of Posture and Positioning  ====
- thyroid dysfunction


*Scapular&nbsp;winging of the involved shoulder may be&nbsp;viewable from the posterior&nbsp;and/or lateral views.<ref name="Yang JI">Yang JI, Chang C, Chen S, Wang S, Lin J. Mobilization techniques in subjects with frozen shoulder syndrome: Randomized multiple-treatment trial. Phys Ther 2007;87:1307-1315.</ref>
- Dupuytrens contractures


==== SCREEN: Upper Quarter Exam (UQE)&nbsp;&amp; Neuro Screen (dermatomes, myotomes, reflexes)  ====
- autoimmune disease


*A full&nbsp;UQE should be performed to rule out cervical spine involvement or any neurological pathologies.<ref name="Kelley" />
- the treatment of breast cancer.  
 
==== ROM SCREEN: Active/Passive/Overpressure<u></u>  ====
 
Cervical, Thoracic, Shoulder ROMs with OP as well as rib mobility should be performed.
 
*Scapular substitution frequently accompanies active shoulder motion.<ref name="Kelley" />
 
==== RESISTED MUSCLE TESTS'''&nbsp;'''  ====
 
Shoulder External Rotation (ER)/ Internal Rotation&nbsp;(IR) / ABduction (ABd)&nbsp;(seated) should be performed.
 
*Patients with adhesive capsulitis present with weakness in shoulder ER, IR and ABd relative to the uninvolved side.<ref name="Kelley" />
 
{| width="100%" cellspacing="1" cellpadding="1" class="FCK__ShowTableBorders"
|-
| {{#ev:youtube|wluL8NYSjeQ|300}} <ref> harrisonvaughanpt. Adhesive Capsulitis Screen. Available from: http://www.youtube.com/watch?v=wluL8NYSjeQ [last accessed 01/12/12]</ref>
| {{#ev:youtube|hWrsDywwzxI|300}}<ref> docforjcrm. The Frozen Shoulder Exam. Available from: http://www.youtube.com/watch?v=hWrsDywwzxI [last accessed 01/12/12]</ref>
|}
 
==== 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.<ref name="Vermeulen">Vermeulen HM, Rozing PM, Obermann WR, Cessie S, Vlieland T. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: Randomized clinical trial. Phys Ther 2006;86:355-368.</ref><ref name="Mitsh">Mitsh J, Casey J, McKinnis R, Kegerreis S, Stikeleather J. Investigation of a consistent pattern of motion restriction in patients with adhesive capsulitis. J Man Manip Ther 2004;12:153-159.</ref><ref name="Johnson">Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis. J Orthop Sports Phys Ther 2000;37:88-99.</ref><ref name="Millar">Millar AL, Jasheway PA, Eaton W, Christensen F. A retrospective, descriptive study of shoulder outcomes in outpatient physical therapy. J Orthop Sports Phys Ther 2006;36:403-414.</ref>
*Patients with adhesive capsulitis commonly present with ROM restrictions in a capsular pattern.&nbsp;A capsular pattern is a proportional motion restriction unique to every joint that indicates irritation of the entire joint.<ref name="Mitsh" />&nbsp;The shoulder joint has a capsular pattern where external rotation is more limited than abduction&nbsp;which is more limited than internal rotation&nbsp; (ER limitations &gt; ABD limitations &gt; IR limitations).<ref name="Mitsh" /><ref name="Millar" /> In the case of adhesive capsulitis,&nbsp;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&nbsp;
*Inferior
*Posterior
*Posterior Capsule Stretch
 
In patients with adhesive capsulitis, the <u>anterior </u>and <u>inferior </u>capsule will be the most limited but joint mobility will be ''restricted in all directions''.<ref name="Mitsh" />
 
==== SPECIAL TESTS&nbsp;  ====
 
Yang et al. investigated the reliability of three function-related tests in patients with shoulder pathologies via a non-experimental study (See Resources for scoring guide):<ref name="Yang J">Yang J, Lin J. Reliability of function-related tests in patients with shoulder pathologies. J Orthop Sports Phys Ther 2006;36:572-576.</ref>&nbsp; [[Image:Yang 2006 FUnctional Tests.JPG|thumb|right|150x300px|Figure 1. Taken from "Reliability of function-related tests in patients with shoulder pathologies." by Yang et al, 2006, J Orthop Sports Phys Ther, 36, p.572-576.]]
 
'''''Hand-to-neck''''' (Figure 1A)
 
*Shoulder flex + abduction + ER
*Similar to ADLs like combing hair, putting on a neclace
 
'''''Hand-to-scapula''''' (Figure 1B)
 
*Shoulder ext + adduction + IR
*Similar to ADLs like snapping a bra, putting on a jacket, getting into back pocket
 
'''''Hand-to-opposite scapula''''' (Figure 1C)
 
*Shoulder flex + horiz ADDuction
 
''NOTE:'' These tests require appropriate elbow, scapulothoracic, and thoracic mobility. Be sure to clear these areas 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&nbsp;the three&nbsp;tests&nbsp;was excellent, ranging&nbsp;from 0.83-0.9.&nbsp;Correlation between the three was&nbsp;moderate (r=0.64 to 0.66). <ref name="Yang J">Yang J, Lin J. Reliability of function-related tests in patients with shoulder pathologies. J Orthop Sports Phys Ther 2006;36:572-576.</ref>
 
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.
 
==== <u>Other:</u>  ====
 
No specific clinical test for adhesive capsulitis&nbsp;has been reported in the literature and there remains no gold standard to diagnose adhesive capsulitis.<ref name="Walmsley" />&nbsp;While there are no 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" />&nbsp;The following are tools that can be used to help determine the stage of adhesive capsulitis and/or irritability status.
 
'''Consensus was achieved on eight clinical identifiers clustered into two discrete domains (pain and movement) as well as an age component.<ref name="Walmsley" />'''
 
'''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 &gt; 35 years of age'''
 
== Medical Management (current best evidence)  ==
 
Although Adhesive Capsulitis is a self-limiting condition, it can take up to two to three years for symptoms to resolve and some patients may never fully regain full motion.<ref name="Blanchard" /> Therefore, it is important for patients to undergo treatment for pain, loss of motion, and limited function rather than take the 'wait-and-see' approach. Various interventions have been researched that address treatment of the synovitis and inflammation and modify the capsular contractions such as oral medications, corticosteroid injections, distension, manipulation, and surgery. Even though many of these treatments have shown significant benefits over no intervention at all, definitive management regimens remain unclear. It has been discussed that the primary treatment for adhesive capsulitis should be based on physical therapy and anti-inflammatory measures;<ref name="Brue" /> however, these outcomes are not always superior to other interventions.<ref name="Kelley" />
 
==== Corticosteroid Injections  ====
 
{| width="40%" cellspacing="1" cellpadding="1" border="0" align="right" class="FCK__ShowTableBorders"
|-
| align="right" |
{{#ev:youtube|UVNullyWQv8|250}} <ref>PixmedAS. 3D MEDICAL ANIMATION Shoulder - Pixmed . Available from: http://www.youtube.com/watch?v=UVNullyWQv8[last accessed 15/12/12]</ref>
 
|}
 
Corticosteroid injections have been used to manage inflammation for many years. It is recommended for adhesive capsulitis based on the belief that inflammation is key in the early stage of the condition the corticosteroid will have an anti-inflammatory effect, diminishing the painful synovitis occurring within the shoulder.<ref name="Kelley" /><ref name="Bal" />&nbsp;This "chemical ablation of synovitis" limits the development of fibrosis (or adhesions) within the capsule, potentially shortening the natural history of the disease.<ref name="Bal" /><ref name="Dias" />&nbsp;Thus&nbsp;they&nbsp;are thought to be more useful in the early, painful and freezing stage of the condition due to the involvement of inflammation, rather than in the latter stages when fibrous contractures are more apparent.<ref name="Brue" /><ref name="Blanchard" /><ref name="Dias" /><ref name="Neviaser">Neviaser AS, Hannafin JA. Adhesive Capsulitis: A Review of Current Treatment. The Am J Sports Med 2010;38:2346-56.</ref>
 
Methyl-prednisolone and Triamicinolone have both been found to be effective for injection. There is no evidence suggesting the most effective treatment dose or administration site; however, the majority of the studies used 20-40 mg injected via an anterior or posterior approach.<ref name="Blanchard" />&nbsp;
 
Many studies have been performed and reviewed comparing corticosteroid injections to physical therapy but contradictory results have arisen.&nbsp;Upon further review, it has been concluded that corticosteroid injections provide significantly greater short-term benefits (4-6 weeks), especially in pain relief, but there is little to no difference in outcomes by 12 weeks compared to physical therapy.<ref name="Brue" /><ref name="Bal" /><ref name="Kelley" /><ref name="Blanchard" /><ref name="Neviaser" /><ref name="Buchbinder">Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2009;1:CD004016.</ref>&nbsp;It is important to note that the majority of studies looking at corticosteroid injection as a treatment option do not define what stage the patients are in and had variations in volumes of corticosteroid used. It has been shown that benefits may not only be dose dependent but dependent on the duration of symptoms as well,<ref name="Blanchard" /><ref name="Dias" /> thus the earlier the injection is received, the quicker the individual will recover. Contraindications do exist due to the use of corticosteroids and include a history of infection, coagulopathy, or uncontrolled diabetes.<ref name="Blanchard" />
 
Ultimately, corticosteroid injections have shown to have success rates ranging from 44-80%<ref name="Brue" />&nbsp;with rapid pain relief and improved function occurring mainly in the first weeks of treatment. Thus, injections should be suggested to patients with pain as their predominant complaint in the early stage of adhesive capsulitis.<ref name="Bal" /><ref name="Kelley" />&nbsp;Though intra-articular steroid injection may be beneficial early on, its effect may be small and not well maintained<ref name="Buchbinder" />&nbsp;and thus should be offered in conjunction with physical therapy.<ref name="Bal" /><ref name="Blanchard" />
 
'''Recommendation:'''
 
*Injection for relieving shoulder disability and pain and physical therapy for improving motion in the painful freezing stage.<ref name="Kelley" /><ref name="Dias" />
*If patients fail to progress within 3-6 weeks with physical therapy alone or patient's symptoms worsen, should be offered the option of a corticosteroid injection.<ref name="Kelley" />
 
==== Manipulation Under Anesthesia (MUA)  ====
 
{| width="45%" cellspacing="1" cellpadding="1" border="0" align="right" class="FCK__ShowTableBorders"
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| align="right" | <br>
| {{#ev:youtube|HtEq2EVlM_w|300}} <ref>Dr. HC Chang. Manipulation Under Anaesthesia of Frozen Shoulder. Available from: http://www.youtube.com/watch?v=HtEq2EVlM_w [last accessed 01/12/12]</ref>
|}
 
Manipulation under anesthesia involves a controlled and&nbsp;forced, end-range positioning of the humerus relative to the glenoid in physiologic planes of motion (flexion, abduction, rotation) in patients with an anesthetic block to the brachial plexus. The block allows the shoulder muscles to completely relax so that the force may actually reach the capsuloligamentous structures.<ref name="Kelley" />&nbsp;Traditionally long lever arms were used, but now short lever arm techniques are utilized to minimize potential risks.<ref name="Kelley" /><ref name="Boyles" />&nbsp;Although success rates are high, ranging from 75-100%,<ref name="Kelley" /> manipulations are considered a last resort and are not indicated unless symptoms persist in spite of adequate conservative treatment for six months.<ref name="Dias" /><ref name="Kelley" /><ref name="Brue" /><ref name="Neviaser" /> This is due to the numerous risks and complications such as: dislocation, glenoid, scapular, or humeral fracture, nerve palsy, rotator cuff tear, hemarthrosis, labral tears, and traction injuries of the brachial plexus or a peripheral nerve.<ref name="Dias" /><ref name="Kelley" /><ref name="Brue" /><ref name="Neviaser" />&nbsp;However, it has been shown that manipulations are the most reliable way to improve range of motion and reduce pain and disability in patients resistant to phyiscal therapy<ref name="Dias" /><ref name="Brue" />&nbsp;and these complications can be minimized with proper techniques and precautions. A good prognosis is often indicated if an audible and palpable release of the tissue occurs during the manipulation.<ref name="Kelley" />
 
An extensive post-manipulation program begins immediately after release of the capsule.<ref name="Kelley" /><ref name="Boyles" />&nbsp;They are often prescribed active assisted range of motion exercises that they are to perform every two hours at home, when awake, for the next 24 hours. Patients are also instructed to ice their shoulder for 20 minutes every two hours with their hand resting behind their head. Post manipulation programs are designed to maintain gains in shoulder mobility and should specifically address each individual's impairments.<ref name="Kelley" /><ref name="Boyles" />
 
Contraindications to manipulation under anesthesia do exist and include: history of fracture or dislocations, moderate bone loss, or an inability to follow through with post procedure care.<ref name="Kelley" /> Although manipulation under anesthesia has been shown to be effective in improving function and motion in patients with adhesive capsulitis, it is necessary to have more randomized controlled trials comparing this treatment to competing treatments before widespread use is advocated.<ref name="Boyles" />


<br>  
<br>  


===== Translation Mobilization Under Anesthesia  =====
Patients with cerebrovascular accident or myocardial infarction have been reported to be at increased risk. In general, it’s more common in those with sedentary vocations than in manual laborers. <ref name="Review" /><br>


An alternative to traditional MUA, translation mobilization under anesthesia, has been identified in the hopes of avoiding the complications associated with the traditional approach. This procedure involves the use of "gliding techniques with static end-range capsular stress, with a short-amplitude high-velocity thrust, if needed, as opposed to the angular stretching forces in manipulation under anesthesia."<ref name="Kelley" /><ref name="Boyles" />&nbsp;In other words, two to three 30-second sets of low-velocity, oscillatory mobilizations (Maitland Grade IV-IV+) are performed initially in the same directions as traditional manipulation under anesthesia (anteriorly, posteriorly, and inferiorly). If an immediate increase in passive range of motion is not noted, a high-velocity, low-amplitude manipulation&nbsp;may be&nbsp;performed. This technique appears to be a safe and efficacious alternative for treatment of patients resistant to conservative treatment; however, higher level studies are needed for verification.<ref name="Kelley" />&nbsp;
== Characteristics/Clinical Presentation  ==


'''Recommendation:'''
Idiopathic adhesive capsulitis is characterized by multiple stages.


*If a patient has persistent symptoms, particularly in decreased shoulder motion, after at least 6 months of conservative treatment, manipulation under anesthesia is an effective technique to improve mobility, pain and disability.
Many scientists describe 3 clinical phases:
*Contraindications and complications do exist and should be relayed to the patient.


==== Arthroscopic Capsular Release  ====
- the painful stage


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- &nbsp;the frozen or adhesive stage&nbsp;
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| {{#ev:youtube|uidyT2L3z1I|300}} <ref> Vivek Agrawal, theshouldercenter.com. Frozen Shoulder Surgery: Mystery of Adhesive Capsulitis. Available from: http://www.youtube.com/watch?v=uidyT2L3z1I [last accessed 01/12/12]</ref>
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Arthroscopic capsular release is highly preferred over open release&nbsp;in patients with painful, disabling adhesive capsulitis that is unresponsive to at least 6 months of non-operative treatment. It has been found to be a reliable and effective method for restoring range of motion and is especially recommended in diabetics and in post-operative or post-fracture adhesive capsulitis patients.<ref name="Brue" /><ref name="Dias" /> It has become the most popular method of treating nonresponsive adhesive capsulitis despite the lack of higher level trials comparing it to MUA.<ref name="Neviaser" /> This is because it allows a more controlled and selective release of the contracted capsule compared to manipulation which ruptures the capsuloligamentous structures nonspecifically and avoids the complications associated with MUA.<ref name="Kelley" /><ref name="Dias" />&nbsp;Debate exists over which structures should be arthroscopically released with the rotator cuff interval and coracohumeral ligament being the most common structures released.<ref name="Kelley" />&nbsp;  
- the thawing or regressive stage.<ref name="Guler">Guler-Uysal F, Kozanoglu E. , Comparison of the Early Response to Two Methods of Rehabilitation in Adhesive Capsulitis, Swiss Medicine Weekly. 2004 Jun 12; 134(23-24):353-8. Level of evidence A2.</ref><ref name="Anton">H.A. Anton, MD, FRCPC, Frozen Shoulder, Canadian Family Physician, 1993 August; 39: 1773–1778.</ref>&nbsp;  


<br>  
<br>  


<br> '''Recommendation:'''
The difference between phase 1 and 2 is not very explicit, but an intra-articular anesthetic injection can be used to discriminate between these stages.


*If patient is unresponsive to at least 6 months of conservative treatment, arthroscopic capsular release alone or in conjunction with manipulation has been shown to be effective in restoring range of motion.  
Stage 1 is characterized by a gradual onset of pain typically referred to the deltoid insertion. Pain is the main initial complaint. It is usually achy at rest and sharper with movement. Patients often report pain at night and an inability to sleep on the affected side. During examination, an empty end feel at the extremes of motion can be observed. Forward flexion, abduction and rotation may worsen the pain. Patients can also indicate limited motion. In this stage, duration of symptoms is generally less than 3 months. <ref name="Review" />&nbsp;Motion can be fully restored, when pain is relieved by an intra-articular anesthetic injection.  
*Avoids complications associated with manipulation under anesthesia and is recommended in diabetics and post-op or post-fracture adhesive capsulitis patients.


==== Other  ====
Stage 2 represents a combination of acute synovitis and progressive capsular contracture. Pain persists and may be more severe. Motion is restricted in forward flexion, abduction, and internal and external rotation. Duration of symptoms can range from 3 to 9 months. <ref name="Review" /> The limitation cannot be fully restored.


<u>Non-steroidal anti-inflammatory drugs (NSAIDs)</u> have traditionally been given to patients with adhesive capsulitis but there is no high level evidence that confirms their effectiveness.<ref name="Dias" /><ref name="Neviaser" />&nbsp;<u>Oral steroids </u>have also been utilized in these patients and result in some improvement in function, but their effects have not shown long-term benefits and combined with their known adverse side effects, should not be regarded as routine treatment.<ref name="Dias" /><ref name="Neviaser" /><ref name="Buchbinder Oral">Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev 2009;1:CD006189.</ref>  
In stage 3, the frozen stage, the main complaint is significant stiffness with decreased range of motion. Pain may still be present at the end range of motion and occasionally at night. Physical examination reveals a sense of mechanical block or tethering at the ends of motion. Symptoms have typically been present for 9 to 15 months at this point. <ref name="Review" />  


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Stage 4, the chronic stage, has also been termed the thawing stage. Pain is minimal, and a gradual improvement in motion can occur.<ref name="Review" /> This stage typically lasts 15 to 24 months. <ref name="Kelley">Kelley MJ, McClure PW, Leggin BG., Frozen shoulder: evidence and a proposed model guiding rehabilitation, Journal of Orthopedics &amp;amp;amp;amp;amp;amp;amp; Sports Physical Therapy. 2009 Feb;39(2):135-48. Level of evidence D.</ref>  
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{{#ev:youtube|H9xJxQuR1hk|300}} <ref>Lennard Funk. Hydrodilatation_shoulderdoc_01.mov. Available from: http://www.youtube.com/watch?v=H9xJxQuR1hk[last accessed 15/12/12]</ref>  


|}
Also it is not unusual for a patient to develop a frozen shoulder on the opposite side after the original condition has improved.<ref name="Review" />


Another technique that shows some short-term benefit with rapid relief of symptoms is <u>distension arthrography</u>. This technique involves the injection of a solution (saline alone or combined w/ corticosteroids) causing rupture of the capsule by hydrostatic pressure.<ref name="Brue" />&nbsp;It is still undetermined whether joint distension with saline solution combined with corticosteroids provides more benefit than distension with saline alone or corticosteroid injection alone.<ref name="Brue" />&nbsp;There is a lack of reliable evidence when determining the effectiveness of this technique and further research needs to be performed to verify any clinical benefit.<ref name="Brue" /><ref name="Neviaser" /><ref name="Buchbinder Distension">Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev 2009;1:CD007005.</ref>
== Differential Diagnosis  ==


<u>Suprascapular nerve blocks </u>are thought to temporarily disrupt pain signals to allow "normalization of the pathological, neurological procresses perpetuating pain and disability."<ref name="Neviaser" />&nbsp;There is some evidence of benefit with suprascapular nerve blocks, though the exact mechanism behind this benefit remains unclear and higher level evidence is needed to establish this as&nbsp;a treatment&nbsp;for adhesive capsulitis.  
Rotator cuff tendinosis, subacromial bursitis (impigment syndrome), rotator cuff tear, cervical radiculopathy, any fracture or dislocation of the shoulder, arthritis, thoracic outlet syndrome.&nbsp;<ref>Richard B. Birrer, Francis G. O’Conner, Sports medicine for the primary care physician, p.512-513, 3th Edition, 2004, CRC Press LLC, Boca Raton, Florida</ref>


==== Medical Management Conclusion  ====
Magnetic resonance imaging (MRI) helps with the differential diagnosis by identifying soft tissue abnormalities of the rotator cuff and labrum. <ref name="Kelley" /><br>


According to a Cochrane review by Green et al.,<ref name="Green" /> there is little evidence to support or refute the use of any of the common interventions listed for adhesive capsulitis. There are also no studies with objective data supporting the timing of when to switch to invasive treatments such as manipulation under anesthesia or arthroscopic release, and thus these are not performed until 6 months of conservative treatment have been unsuccessful. Unfortunately this exposes more than 40% of patients with adhesive capsulitis to a long period of disability.<ref name="Brue" />
== Diagnostic Procedures  ==


Treatment should be tailored to the stage of the disease because the condition has a predictable progression.<ref name="Dias" /><ref name="Neviaser" /> During the painful freezing stage, treatment should be directed at pain relief with pain guiding activity. NSAIDs, physical therapy and steroid injection&nbsp;are all suggested interventions during this stage of adhesive capsulitis.<ref name="Blanchard" /><ref name="Dias" />&nbsp;Once the patient is in the adhesive stage, injections are no longer indicated because the inflammatory stage of the disease has passed. Instead the focus should switch to more aggressive stretching and MUA or surgical release if symptoms are unresponsive to conservative treatment and quality of life is compromised.<ref name="Dias" /><ref name="Kelley" /><ref name="Brue" /><ref name="Neviaser" /><br>
add text here related to medical diagnostic procedures


== Physical Therapy Management (current best evidence) ==
== Outcome Measures ==


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.<ref name="Ruiz">Ruiz J. Positional Stretching of the Coracohumeral Ligament on a Patient with Adhesive Capsulitis: A Case Report. The Journal of Manual and Manipulative Therapy Vol 17: Number 1: 58-63.</ref> Non-operative interventions include patient education, modalities, stretching exercises, and joint mobilizations.<ref name="Kelley" /><ref name="Cleland" /> Levine et al. reported that 89.5% of ninety eight patients with frozen shoulder responded well to non-operative management.<ref name="Kelley" />&nbsp;Reviewed studies suggest that many patients have benefited from physical therapy and showed reduced symptoms, increased mobility, and/or functional improvement.<ref name="Cleland" /> However,&nbsp;a Cochrane&nbsp;Review&nbsp;by Green et al.&nbsp;states that there is, “no evidence that physiotherapy alone is of benefit for adhesive capsulitis.”<ref name="Green">Green S, Buchbinder R, Hetrick SE. Physiotherapy interventions for shoulder pain (Review). The Cochrane Library 2010;9:1-105.</ref>
add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]])  


==== '''Importance of Patient Education''' ====
== Examination ==


For the treatment of adhesive capsulitis, patient education is essential&nbsp;in helping to ''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.&nbsp;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 critical in relieving symptoms.<ref name="Kelley" />
To differentiate between adhesive capsulitis and other pathologies multiple shoulder-specific outcome measures are available, such as:


==== '''Modalities'''  ====
- the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH)


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.<ref name="Kelley" /> In a randomized study by Bal et al., patients improved with combined therapy which involved <u>hot and cold packs</u> applied ''before and after shoulder exercises ''were performed.<ref name="Bal">Bal A, Eskioglu E, Gulec B, Aydog E, Gurcay E, Cakci A. Effectiveness of corticosteroid injection in adhesive capsulitis. Clinical Rehabilitation 2008; 22:503-512.</ref> 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.<ref name="Jewell" /> A Cochrane Review by Green et al.&nbsp;showed that, “There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis.”<ref name="Green">Green S, Buchbinder R, Hetrick SE. Physiotherapy interventions for shoulder pain (Review). Cochrane Database Syst Rev 2010;9:CD001156.fckLRfckLR&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;nbsp;fckLRfckLRAs stated previously, it has been suggested that treatment be customized to the patient based on what stage of the condition they are in.fckLRfckLR==== '''Initial Phase: Painful, Freezing''' ====fckLRfckLR&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Pain relief &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;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, and activities that are pain-free are allowed.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;nbsp;Better results have been found in patients who performed pain-free exercise, rather than intensive physical therapy.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;ref name="Dias" /&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; In patients with high irritability, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;range of motion exercises&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; performed with ''low intensity and a short duration ''can alter joint receptor input, reduce pain, and decrease muscle guarding. &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Stretches &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;may be performed but only&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;nbsp;held from one to five seconds at a pain-free range, two to three times a day.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;ref name="Kelley" /&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 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 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;pendulum exercise, passive supine forward elevation, passive external rotation &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;with the arm in approximately forty degrees of abduction in the plane of the scapula, and &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;active assisted range of motion &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;in extension, horizontal adduction, and internal rotation.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;ref name="Kelley" /&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;nbsp; (See Resources: Figure 2 Kelley and Figure 3 Kelley). In a study by Bal et al.,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;nbsp;concominant&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;nbsp;exercises&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;nbsp;included &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;isometric strengthening in all ranges &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;once motion was reached in 90% of normal ranges, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;theraband exercises in all planes, scapular stabilization exercises, and later, advanced muscular strengthening &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/u&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;with dumbbells.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;ref name="Bal"&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;Bal A, Eskioglu E, Gulec B, Aydog E, Gurcay E, Cakci A. Effectiveness of corticosteroid injection in adhesive capsulitis. Clinical Rehabilitation 2008; 22:503-512.</ref>
- Simple Shoulder Test (SST)  


==== Initial Phase: Painful, Freezing  ====
- Penn Shoulder Score


As stated previously, treatment should be customized to each individual based on what stage/phase of adhesive capsulitis they are in.
- American Shoulder and Elbow Surgeons (ASES) score


<u>Pain relief </u>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 and pain-free activities should be allowed. Better results have been found in patients who performed pain-free exercise, rather than intensive physical therapy<ref name="Dias" /> In patients with high irritability, <u>range of motion exercises</u> performed with <u>low intensity and a short duration</u> can alter joint receptor input, reduce pain, and decrease muscle guarding. <u>Stretches</u> may be held from one to five seconds at a pain-free range, two to three times a day.<ref name="Kelley" /> 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 <u>pendulum exercise, passive supine forward elevation, passive external rotation </u>with the arm in approximately forty degrees of abduction in the plane of the scapula, and <u>active assisted range of m</u>otion in extension, horizontal adduction, and internal rotation.<ref name="Kelley" /> (See Resources: Figure 1 and Figure 2).&nbsp;
- the Constant-Murley score.  


In a single-patient case-report by Ruiz et al.,p<u>ositional stretching of the coracohumeral ligament </u>was performed for a patient in the first phase of adhesive capsulitis.<ref name="Ruiz" /> The patient's [[DASH Outcome Measure|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.<ref name="Ruiz" /> (See Resources: Figure 3).
<br>  
 
In the case of adhesive capsulitis, physical therapy can also be a complement to other therapies (such as steroid injections as discussed previously), especially to improve the range of motion of the shoulder.<ref name="Brue" /> In a study by Bal et al., concominant exercises to steroid injections 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.<ref name="Bal" />
 
==== '''Second Phase: Adhesive&nbsp;'''  ====
 
During the adhesive phase, the focus of treatment should be shifted towards&nbsp;<u>more aggressive stretching exercises</u> in order to improve range of motion. The patient should perform <u>low load, prolonged stretches</u> in order to produce plastic elongation of tissues and avoid high load, brief stretches, which would produce high tensile resistance.<ref name="Dias" />
 
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.<ref name="Brue" /> During the second phase of treatment, <u>movement with mobilization </u>and <u>end range mobilization </u>have shown to be successful, according to a randomized multiple treatment trial by Yang et al.<ref name="Yang JI" /> In this trial, the patients 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. Mobilization with movement also&nbsp;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, whereas the goal for mobilization with movement was to restore pain-free motion to the joints that had painful limitation of range of motion.<ref name="Yang JI" />
 
A controlled, cohort study, performed by Gaspar&nbsp;and Willis<ref name="Gaspar" />, showed that physical therapy paired with dynamic splinting had better outcomes compared to&nbsp;physical therapy alone or dynamic splinting alone. The patients in this group of combined treatments received physical therapy twice a week and a 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. The 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.&nbsp;The combination of physical therapy with&nbsp;dynamic splinting had significant&nbsp;improvements in&nbsp;active, external rotation in patients with adhesive capsulitis.<ref name="Gaspar">Gaspar P, Willis B. Adhesive capsulitis and dynamic splinting: a controlled, cohort study. BMC Musculoskeletal Disorders 2009;10:111.</ref>
 
==== '''Third Phase: Resolution'''  ====
 
During stage three, also known as the Resolution Phase, treatment is progressed primarily by <u>increasing stretch frequency and duration</u>, 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 <ref name="Kelley" />. (See Resource: Figure 4).
 
==== Helpful Manual Techniques&nbsp;  ====
 
Mechanical changes that occur as a result of 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. These techniques are intended to increase joint mobility by inducing changes in synovial fluid formation. '''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.<ref name="Vermeulen" /> In a study by Vermeulen et al., patients were given inferior, posterior, and anterior glides as well as a distraction to the humeral head. These techniques were performed at greater elevation and abduction angles if glenohumeral joint range of motion increased during treatment. Patients who received HGMT received these mobilizations at Maitland Grades III and IV according to the subjects' tolerance with the intention of "treating the stiffness." Patients were allowed to report a dull ache as long as it did not alter the execution of the mobilizations or persist for more than four hours after treatment. However, patients who received low-grade mobilization techniques (LGMT) were given Mailtand Grades I or II without the report of any pain. 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. It can then be concluded that high-grade mobilization techniques appear to be more effective for increasing joint mobility and reducing disability.<ref name="Vermeulen" /> Based on prior knowledge regarding the use of Mailtand Grades for mobilizations, one would assume HGMT would be more beneficial during later adhesive stages of adhesive capsulitis, while LGMT would provide more benefit during early painful stages. However, future studies are needed to investigate whether HGMTs applied during earlier stages of adhesive capsulitis are as effective as in this particular study.<ref name="Vermeulen" />
 
In a randomized clinical trial, Johnson et al. reported that joint mobilizations, in particular <u>posterior glenohumeral glides</u>, can help decrease deficits in external rotation, more so than anterior glenohumeral glides.<ref name="Johnson" /> A significant difference in external rotation 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.<ref name="Johnson" /> (See Resources: Figure 5 and Figure 6)
 
Another randomized controlled trial, performed by Zimmerman et al., found results consistent with the trial by Johnson et al., in which posteriorly directed joint mobilizations showed greater improvements in external rotation that anteriorly directed joint mobilizations.<ref name="Ruiz" /> Yang et al. performed a multiple treatment trial using combinations of end-range mobilization, mid-range mobilization, and <u>mobilization with motion </u>in patients with adhesive capsulitis.<ref name="Yang JI" /> Improved motion and function was found at 12 weeks with <u>end-range mobilization</u>. It was concluded that end range mobilization was more effective than mid-range mobilization in increasing motion and functional mobility.<ref name="Yang JI" /> 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.<ref name="Jewell" />
 
==== '''Rationale Behind Stretching'''  ====
 
Research regarding connective tissue stretch duration and intensity has produced three findings. First, high intensity, short duration stretching <u>aids the elastic response</u>, while low intensity, prolonged duration stretching <u>aids the plastic response</u>. Secondly, a direct <u>correlation exists between the resulting proportion of plastic, permanent elongation and the duration of a stretch</u>. Lastly, a direct <u>correlation exists between the degree of either trauma or weakening of the stretched tissues and the intensity of a stretch</u>. 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.<ref name="Ruiz" /><br>  


==== '''Progression'''  ====
Also a full upper-quarter examination is performed to rule out cervical spine and neurological pathologies.


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.<ref name="Kelley" />&nbsp;Progression for stretching via dynamic splinting is&nbsp;based on ''patient tolerance'', as well. In the controlled cohort study by Gaspar&nbsp;and Willis,&nbsp;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.<ref name="Gaspar" />
With frozen shoulder, the examination of the shoulder typically reveals significant limitation of both active and passive elevation, usually less than 120°. These motion limitations are stage dependent. A greater than 50% reduction in passive external rotation or less than 30° of external rotation, when measured with the arm at the side, is also a common finding.  


----
To explore muscle function associated with shoulder movements, muscle strength test examination may be used. An isokinetic machine is proved to be reliable and is frequently used in clinics to investigate muscle strength.<ref name="Kelley" /><br>


<br>  
== Medical Management <ref name="Review" /><br> ==


'''Dry Needling Techniques'''<br>  
*Intra-articular steroid injections
*Manipulation under anesthesia (MUA)
*Suprascapular nerve block (SSNB)
*Hydrodalition
*Arthroscopy
*Open capsular release <br>


Movements restrictions in the shoulderas seen in adhesive capsulitis may also be due to muscle shortening.Trigger Points may develop in the shoulder muscles which may also mimic the symptoms associated with adhesive capsulitis.Dry Needling techniques can be used to reset these muscles which will pave a path for better usage of other manual techniques adressing the articular component of the joint.Muscles to be needled are Infraspinatus,Teres Minor &amp; Major,Subscapularis,Pecterolis Major &amp; Minor and the anterior Deltoid depending on the movement restriction presentation<br>  
== Physical Therapy Management <br> ==


<br>  
There are many types of treatment used to manage the frozen shoulder, but there is no consensus on how best to manage patients with this painful condition. Physical therapy is the most consistently prescribed treatment to prevent capsular contraction and to improve motion in the latter stages of this disease. However there is no evidence found that physiotherapy alone is of benefit in adhesive capsulitis. <ref name="Review" />  


==== '''What We Need'''  ====
Traditionally, physiotherapists treat adhesive capsulitis with a variety of interventions including mobilizations, stretching, strengthening and home exercises, to restore range of movement and function. Steroid injections are used to reduce the initial pain. In short term, they seem to be more beneficial than physiotherapy. The effect appears to be the most significant around 6 to 7 weeks. Thus the combination of physical therapy and steroid injections can provide a more effective and streamlined care package for patients. A ‘Wait-and-see policy’ is certainly not a good treatment for patients with a frozen shoulder. Both physiotherapy as corticosteroid injections alone, are more effective than no treatment at all. <ref>Blanchard V, Barr S, Cerisola FL., The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review., Physiotherapy. 2010 Jun;96(2):95-107. Epub 2009 Nov 12. Level of evidence A1.</ref>


“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."<ref name="Brue" /> 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.<ref name="Cleland" />  
For patients in stage 1, the main goal of therapy is to decrease the pain. Gentle stretching and active motion within the pain-free range appear to be sufficient. Also pendulum exercises can be applied. Mobilizations of the shoulder joint will be performed by the physiotherapist. All activities that provoke pain should be avoided. Therapeutic modalities, such as ice, heat, massage, ultrasound, acupuncture and electrotherapy, can be employed for muscle relaxation and to relieve the pain.<ref name="Review" />  


==== '''REHABILITATION PROTOCOL FOR ADHESIVE CAPSULITIS'''  ====
In stage 2, patients have the additional goal of minimizing capsular adhesions and restrictions of motion.<ref name="Review" /> Griggs, et al. revealed a significant benefit from participating in a "Four-direction shoulder-stretching exercise program" in stage 2 idiopathic adhesive capsulitis. 90% of the patients gained significant increases in ROM of external and internal rotation, flexion and abduction in the first few months and maintained ROM through this daily program. The use of low-load prolonged-duration stretch, combined with the therapeutic principle of increased time at end range, allows the patient to reduce contracture by achieving permanent elongation of connective tissue. <ref name="Gaspar" />


<br>''[[Image:Rehabilitation Protocol for Adhesive Capsulitis.doc|thumb|left|An example of a Physical Therapy Protocol for Adhesive Capsulitis]]&nbsp;''<ref name="Kelley" /><ref name="Ruiz" /><ref name="Dias" /><ref name="Bal" /><ref name="Yang JI" /><ref name="Vermeulen" /><ref name="Gaspar" />  
During stage 3, aggressive stretching should be the mainstay of therapy. Active warm-up to enhance soft tissue circulation is performed. Prolonged, low-load stretching is more effective than brief, high-load stretching.<ref name="Review" /> Stretches may be held from 1 to 5 seconds at the relatively pain-free range, 2 to 3 times a day. Tissue stress is progressed by increasing stretch frequency and duration, while keeping the intensity in tolerable limits. The patient may be asked to hold the stretch for longer periods and increase the number of sessions per day. A consistent home exercise program is important, because daily exercise is effective in relieving symptoms.<ref name="Kelley" /> Use of the Shoulder Dynasplint System (SDS) showed an effective adjunct "home therapy" for adhesive capsulitis. 80 to 90 hours of endrange stretching as home therapy in addition to physical therapy is considered to be responsible for the greatest change in active external rotation.&nbsp;<ref name="Gaspar" />  


From the information we have gathered from the literature review of rehabilitation for adhesive capsulitis, we have put together an example of a physical therapy protocol for practicing clinicians. It is broken up by phase of the disorder and also includes&nbsp;suggestions for the home exercise program.  
Specific therapy for stage 4 does not greatly differ from stage 3. Further cuff strengthening including conditioning is initiated as motion improves. <ref name="Review" /><br>


== Key Research  ==
== Key Research  ==


[http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1nGQFE-05Nk05h_HX5CbzMER6VlGUS2VZ2gCnt9AOQvy_GJYuT Vermeulen et al. (2006). Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: Randomized clinical trial.] <br>The purpose of this RCT was to compare high-grade and low-grade mobilization techniques in patients with adhesive capsulitis. One hundred subjects who had symptoms for &gt;3 months and &gt;50% loss of passive range of motion were included and assessed at baseline as well as 3, 6, and 12 months post-treatment. Primary outcome measures included the Shoulder Rating Questionnaire (SRQ), Shoulder Disability Questionnaire (SDQ), active and passive range of motion. Overall, both groups showed improvements at 12 months with the high-grade mobilization group being slightly more effective at reducing disability and improving joint mobility.
add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  
 
<br>[http://www.ncbi.nlm.nih.gov/pubmed/20420956 Blanchard et al. (2010). The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitits: A systematic review.]<br>The authors of this study deemed six articles eligible for inclusion according to the PEDro scale for methodological quality. All studies had random allocation to either an injection group or a physical therapy intervention group. There was a medium effect for corticosteroid injections compared to physical therapy for the outcomes of pain, passive external rotation and shoulder disability at six weeks. There was a small effect favoring corticosteroid injections for pain, passive external rotation and shoulder disability at 12-16 weeks and 26 weeks, and pain and shoulder disability at 52 weeks.
 
[http://www.physiotherapyjournal.com/article/S0031-9406(05)60847-4/abstract Cleland et al. (2002). Physical therapy for adhesive capsulitis: A systematic review.] <br>The authors of this study reviewed 12 non-operative experiemental or descriptive research-based outcomes studies published between 1990 and 2000 to determine the efficacy of physical therapy for patients with adhesive capsulitis. Quality scores from the 12 studies ranged from 38-69% (mean 54%). Of the studies that were reviewed, physical therapy was beneficial at reducing symptoms, increasing mobility and/or improving function. However, poor standardasion of terminology, methodology and outcome measures undermines the validity of these studies and limits their clinical application.<br><br>  


== Resources <br>  ==
== Resources <br>  ==


[[Image:Figure 1.jpg|thumb|left|150x450px|FIgure 1: Forward Flexion; External Rotation; Extension]]&nbsp;[[Image:Figure 2.jpg|thumb|right|150x450px|Figure 2: Internal Rotation; Horizontal Adduction; Pulleys for Elevation]][[Image:CHL Stretch.JPG|thumb|center|400x250px|Figure 3: Coracohumeral Ligament Stretch]]&nbsp;
add appropriate resources here <br>  
 
[[Image:Elevation and ER.JPG|thumb|left|450x250px|Figure 4: Elevation and ER with Cane]]
 
[[Image:Posterior Mobs.jpg|thumb|left|450x250px|Figure 5: Posterior Mobilizations]][[Image:Anterior Mobs.jpg|thumb|right|500x300px|Figure 6: Anterior Mobilizations]]
 
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{| width="753" cellspacing="1" cellpadding="1" border="2" align="center" style="width: 753px; height: 590px"
|+ '''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 + external rotation)*'''
 
|-
| 0&nbsp;&nbsp; The fingers reach the posterior median line of the neck with the shoulder in full abduction and external rotation without wrist extension.
|-
| 1&nbsp;&nbsp; The fingers reach the median line of the neck but do not have full abduction and/or external rotation.
|-
| 2&nbsp;&nbsp; The fingers reach the median line of the neck but with compensation by adduction in the horizontal plane or by shoulder elevation
|-
| 3&nbsp;&nbsp;&nbsp; The fingers touch the neck
|-
| 4&nbsp;&nbsp; The fingers do not reach the neck
|-
|
'''Hand-to-scapula (shoulder extension + internal rotation)<sup>¤</sup>'''
 
|-
| 0&nbsp;&nbsp; The hand reaches behind the trunk to the opposite scapula or 5cm beneath it in full internal rotation
|-
| 1&nbsp;&nbsp; The hand almost reaches the opposite scapula, 6-15 cm beneath it
|-
| 2&nbsp;&nbsp; The hand reaches the opposite illiac crest
|-
| 3&nbsp;&nbsp; The hand reaches the buttock
|-
| 4&nbsp;&nbsp;&nbsp;Subject cannot&nbsp;move the hand behind the trunk&nbsp;
|-
|
'''Hand-to-opposite scapula (shoulder horizontal adduction)<sup>§</sup>'''
 
|-
| 0&nbsp;&nbsp; The hand reaches to the spine of the opposite scapula in full adduction without wrist flexion
|-
| 1&nbsp;&nbsp; The hand reaches to the spine of the opposite scapula in full adduction
|-
| 2&nbsp;&nbsp; The hand passes the midline of the trunk
|-
| 3&nbsp;&nbsp; The hand cannot pass the midline of the trunk
|-
| <br>
|-
| * '''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.'''
|-
| '''§&nbsp; This test measures an action important for daily activities, such as usin gthe 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  ==
== Clinical Bottom Line  ==


There is no definitive treatment for adhesive capsulitis. However, the literature suggests interventions should be tailored to the stage of the disease based on its progressive nature. During the initial/painful freezing stage, treatment should be directed at pain relief with pain guiding activity. NSAIDs and steroid injection, stretching, strengthening and range of motion exercises, as well as Maitland Grade I-II mobilizations have been shown to improve function and reduce pain and disability. As the patient progresses to the adhesive stage, intervention should focus on aggressive, end-range stretches combined with Maitland Grade III-IV mobilizations. At six months, if functional disability persists despite conservative treatment, mobilizations under anesthesia (MUA) or arthroscopic capsular release may be indicated.<br>  
add text here <br>  


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox"><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1ZIrvZUsS72dd2vp96F6Cy-si4qUkYioDE_3hJ60dpLaqepYed|charset=UTF-8|short|max=10</rss></div>  
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<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1DoqKB8O4L1GKJ0MAYUiQbvNz-cMg0LANKG2a6HNsACwhVFgp5charset=UTF-8|short|max=10</rss><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1dgaXX1bzyL1dEpqah5d4xlJaRyL4T-Ctjdl_jpDl4ydXs7MeZcharset=UTF-8|short|max=10</rss><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1hAmdQvDK722TPBtI1Kc0BB_OvGTce0LFGVh2ovcyK2PPRIMxQcharset=UTF-8|short|max=10</rss><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=16IogA8e1N8CKdNEZKU3CZ_mxpoy1T7zcoK9vt0oFAJSIuFIYlcharset=UTF-8|short|max=10</rss><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1dwOEnJFpGXu0SGyODRJiKJdwoRLcUf5jeXvlz68uWB66RTg2Echarset=UTF-8|short|max=10</rss><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1V5bX9N3xU3xSJpkGPH9khBY-20TNLDg3k5QgOQL_GC9nIuYjLcharset=UTF-8|short|max=10</rss><rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1Hme278Y-6cb3hBEfs6to-y6rQZlSJX23iNbnAc4GGbBDeok6pcharset=UTF-8|short|max=10</rss>  
</div>  
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />  
<references />  


[[Category:EIM_Residency_Project]] [[Category:Texas_State_University_EBP_Project]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Shoulder]]
[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]]

Revision as of 13:50, 30 July 2013

This article requires a page merger with a similar article of a similar name or containing repeated information. (16 May 2024)

Original Editors - Nina Lefeber

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Search Strategy[edit | edit source]

To search for information about adhesive capsulitis, medical databases, such as Pubmed and PEDro, were used. Keywords I used to find information are adhesive capsulitis, frozen shoulder, treatment AND adhesive capsulitis, exercises AND adhesive capsulitis. To improve the strategy I used the limits on Pubmed: 5 years (published in the last), English (languages), humans (species). The amount of articles is 303.

Definition/Description[edit | edit source]

Adhesive capsulitis, or frozen shoulder, is a condtion in which the capsule of the glenohumeral joint is inflamed. It is characterized by a painful, gradual loss of both active and passive glenohumeral motion, resulting from progressive fibrosis and contracture of the glenohumeral joint capsule. [1] [2] Contracture is defined as shortening of connective tissue (ligaments, tendons, and cartilage) and caused by excessive arthrofibrosis, immobilization, inactivation and adhesions.[3] 

Adhesive capsulitis is described as being either primary or secondary. Primary, or idiopathic, adhesive capsulitis is due to an unknown cause, whereas secondary adhesive capsulitis results from a known cause or surgical event. [4]

Clinically Relevant Anatomy[edit | edit source]

Contracture of the rotator cuff interval (RCI) is prevalent. The RCI forms the triangular-shaped tissue between the anterior supraspinatus tendon edge and upper subscapularis border, and includes the superior glenohumeral ligament and the coracohumeral ligament.

Significant subacromial scarring, loss of the subscapular recess, and inflammation of the long head of the biceps tendon and its synovial sheath is noticed in patients with frozen shoulder. [5]

Epidemiology /Etiology[edit | edit source]

Adhesive capsulitis occurs in 2% to 5% of the population. The majority of patients are female, and especially between the ages of 40 to 60 years. [1][2] The non-dominant hand is more frequently involved, and about 20% to 30% of those affected will develop the condition in the opposite shoulder. 

The causes remain unclear. Twenty percent to 30% of patients will report a history of minor trauma to the shoulder, but there is no further evidence that this is a posttraumatic condition. Others develop this condition due to an unknown cause.

The development of adhesive capsulitis has been associated with:

- diabetes mellitus

- thyroid dysfunction

- Dupuytrens contractures

- autoimmune disease

- the treatment of breast cancer.


Patients with cerebrovascular accident or myocardial infarction have been reported to be at increased risk. In general, it’s more common in those with sedentary vocations than in manual laborers. [1]

Characteristics/Clinical Presentation[edit | edit source]

Idiopathic adhesive capsulitis is characterized by multiple stages.

Many scientists describe 3 clinical phases:

- the painful stage

-  the frozen or adhesive stage 

- the thawing or regressive stage.[6][7] 


The difference between phase 1 and 2 is not very explicit, but an intra-articular anesthetic injection can be used to discriminate between these stages.

Stage 1 is characterized by a gradual onset of pain typically referred to the deltoid insertion. Pain is the main initial complaint. It is usually achy at rest and sharper with movement. Patients often report pain at night and an inability to sleep on the affected side. During examination, an empty end feel at the extremes of motion can be observed. Forward flexion, abduction and rotation may worsen the pain. Patients can also indicate limited motion. In this stage, duration of symptoms is generally less than 3 months. [1] Motion can be fully restored, when pain is relieved by an intra-articular anesthetic injection.

Stage 2 represents a combination of acute synovitis and progressive capsular contracture. Pain persists and may be more severe. Motion is restricted in forward flexion, abduction, and internal and external rotation. Duration of symptoms can range from 3 to 9 months. [1] The limitation cannot be fully restored.

In stage 3, the frozen stage, the main complaint is significant stiffness with decreased range of motion. Pain may still be present at the end range of motion and occasionally at night. Physical examination reveals a sense of mechanical block or tethering at the ends of motion. Symptoms have typically been present for 9 to 15 months at this point. [1]

Stage 4, the chronic stage, has also been termed the thawing stage. Pain is minimal, and a gradual improvement in motion can occur.[1] This stage typically lasts 15 to 24 months. [5]

Also it is not unusual for a patient to develop a frozen shoulder on the opposite side after the original condition has improved.[1]

Differential Diagnosis[edit | edit source]

Rotator cuff tendinosis, subacromial bursitis (impigment syndrome), rotator cuff tear, cervical radiculopathy, any fracture or dislocation of the shoulder, arthritis, thoracic outlet syndrome. [8]

Magnetic resonance imaging (MRI) helps with the differential diagnosis by identifying soft tissue abnormalities of the rotator cuff and labrum. [5]

Diagnostic Procedures[edit | edit source]

add text here related to medical diagnostic procedures

Outcome Measures[edit | edit source]

add links to outcome measures here (also see Outcome Measures Database)

Examination[edit | edit source]

To differentiate between adhesive capsulitis and other pathologies multiple shoulder-specific outcome measures are available, such as:

- the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH)

- Simple Shoulder Test (SST)

- Penn Shoulder Score

- American Shoulder and Elbow Surgeons (ASES) score

- the Constant-Murley score.


Also a full upper-quarter examination is performed to rule out cervical spine and neurological pathologies.

With frozen shoulder, the examination of the shoulder typically reveals significant limitation of both active and passive elevation, usually less than 120°. These motion limitations are stage dependent. A greater than 50% reduction in passive external rotation or less than 30° of external rotation, when measured with the arm at the side, is also a common finding.

To explore muscle function associated with shoulder movements, muscle strength test examination may be used. An isokinetic machine is proved to be reliable and is frequently used in clinics to investigate muscle strength.[5]

Medical Management [1]
[edit | edit source]

  • Intra-articular steroid injections
  • Manipulation under anesthesia (MUA)
  • Suprascapular nerve block (SSNB)
  • Hydrodalition
  • Arthroscopy
  • Open capsular release

Physical Therapy Management
[edit | edit source]

There are many types of treatment used to manage the frozen shoulder, but there is no consensus on how best to manage patients with this painful condition. Physical therapy is the most consistently prescribed treatment to prevent capsular contraction and to improve motion in the latter stages of this disease. However there is no evidence found that physiotherapy alone is of benefit in adhesive capsulitis. [1]

Traditionally, physiotherapists treat adhesive capsulitis with a variety of interventions including mobilizations, stretching, strengthening and home exercises, to restore range of movement and function. Steroid injections are used to reduce the initial pain. In short term, they seem to be more beneficial than physiotherapy. The effect appears to be the most significant around 6 to 7 weeks. Thus the combination of physical therapy and steroid injections can provide a more effective and streamlined care package for patients. A ‘Wait-and-see policy’ is certainly not a good treatment for patients with a frozen shoulder. Both physiotherapy as corticosteroid injections alone, are more effective than no treatment at all. [9]

For patients in stage 1, the main goal of therapy is to decrease the pain. Gentle stretching and active motion within the pain-free range appear to be sufficient. Also pendulum exercises can be applied. Mobilizations of the shoulder joint will be performed by the physiotherapist. All activities that provoke pain should be avoided. Therapeutic modalities, such as ice, heat, massage, ultrasound, acupuncture and electrotherapy, can be employed for muscle relaxation and to relieve the pain.[1]

In stage 2, patients have the additional goal of minimizing capsular adhesions and restrictions of motion.[1] Griggs, et al. revealed a significant benefit from participating in a "Four-direction shoulder-stretching exercise program" in stage 2 idiopathic adhesive capsulitis. 90% of the patients gained significant increases in ROM of external and internal rotation, flexion and abduction in the first few months and maintained ROM through this daily program. The use of low-load prolonged-duration stretch, combined with the therapeutic principle of increased time at end range, allows the patient to reduce contracture by achieving permanent elongation of connective tissue. [3]

During stage 3, aggressive stretching should be the mainstay of therapy. Active warm-up to enhance soft tissue circulation is performed. Prolonged, low-load stretching is more effective than brief, high-load stretching.[1] Stretches may be held from 1 to 5 seconds at the relatively pain-free range, 2 to 3 times a day. Tissue stress is progressed by increasing stretch frequency and duration, while keeping the intensity in tolerable limits. The patient may be asked to hold the stretch for longer periods and increase the number of sessions per day. A consistent home exercise program is important, because daily exercise is effective in relieving symptoms.[5] Use of the Shoulder Dynasplint System (SDS) showed an effective adjunct "home therapy" for adhesive capsulitis. 80 to 90 hours of endrange stretching as home therapy in addition to physical therapy is considered to be responsible for the greatest change in active external rotation. [3]

Specific therapy for stage 4 does not greatly differ from stage 3. Further cuff strengthening including conditioning is initiated as motion improves. [1]

Key Research[edit | edit source]

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

Resources
[edit | edit source]

add appropriate resources here

Clinical Bottom Line[edit | edit source]

add text here

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

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References[edit | edit source]

see adding references tutorial.

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Cite error: Invalid <ref> tag; no text was provided for refs named Review
  2. ↑ 2.0 2.1 Walmsley S, Rivett DA, Osmotherly PG., Adhesive capsulitis: establishing consensus on clinical identifiers for stage 1 using the DELPHI technique., Phys Ther. 2009 Sep;89(9):906-17. Epub 2009 Jul 9. Level of evidence B.
  3. ↑ 3.0 3.1 3.2 Gaspar PD, Willis FB, Adhesive capsulitis and dynamic splinting: a controlled, cohort study, BMC Musculoskelet Disorders, 2009 Sep 7;10:111. Level of evidence B.
  4. ↑ Sam W. Wiesel, John N. Delahay, Essentials of Orthopedic Surgery. 4th Edition, 2010, Springer Science+Business Media LLC, NY (USA).
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Kelley MJ, McClure PW, Leggin BG., Frozen shoulder: evidence and a proposed model guiding rehabilitation, Journal of Orthopedics &amp;amp;amp;amp;amp;amp; Sports Physical Therapy. 2009 Feb;39(2):135-48. Level of evidence D.
  6. ↑ Guler-Uysal F, Kozanoglu E. , Comparison of the Early Response to Two Methods of Rehabilitation in Adhesive Capsulitis, Swiss Medicine Weekly. 2004 Jun 12; 134(23-24):353-8. Level of evidence A2.
  7. ↑ H.A. Anton, MD, FRCPC, Frozen Shoulder, Canadian Family Physician, 1993 August; 39: 1773–1778.
  8. ↑ Richard B. Birrer, Francis G. O’Conner, Sports medicine for the primary care physician, p.512-513, 3th Edition, 2004, CRC Press LLC, Boca Raton, Florida
  9. ↑ Blanchard V, Barr S, Cerisola FL., The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review., Physiotherapy. 2010 Jun;96(2):95-107. Epub 2009 Nov 12. Level of evidence A1.
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