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Clinical Practice Guidelines

MARTIN J. KELLEY, DPT • MICHAEL A. SHAFFER, MSPT • JOHN E. KUHN, MD • LORI A. MICHENER, PT, PhD
AMEE L. SEITZ, PT, PhD • TIMOTHY L. UHL, PT, PhD • JOSEPH J. GODGES, DPT, MA • PHILIP W. MCCLURE, PT, PhD

Shoulder Pain and Mobility
Deficits: Adhesive Capsulitis
Clinical Practice Guidelines Linked to the
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International Classification of Functioning,
Disability, and Health From the Orthopaedic Section
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

of the American Physical Therapy Association
J Orthop Sports Phys Ther 2013;43(5):A1-A31. doi:10.2519/jospt.2013.0302

RECOMMENDATIONS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A2
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
Journal of Orthopaedic & Sports Physical Therapy®

METHODS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4
CLINICAL GUIDELINES:
Impairment/Function-Based Diagnosis.. . . . . . . . . . . . . . . . . . A6
CLINICAL GUIDELINES:
Examination.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A14
CLINICAL GUIDELINES:
Interventions.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A16
SUMMARY OF RECOMMENDATIONS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . A26
AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS.. . . . . . A27
REFERENCES.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A28

REVIEWERS: Roy D. Altman, MD • John DeWitt, DPT • George J. Davies, DPT, MEd, MA
Todd Davenport, DPT • Helene Fearon, DPT • Amanda Ferland, DPT • Paula M. Ludewig, PT, PhD • Joy MacDermid, PT, PhD
James W. Matheson, DPT • Paul J. Roubal, DPT, PhD • Leslie Torburn, DPT • Kevin Wilk, DPT

For author, coordinator, contributor, and reviewer affiliations, see end of text. Copyright ©2013 Orthopaedic Section, American Physical Therapy Association (APTA), Inc,
and the Journal of Orthopaedic & Sports Physical Therapy. The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy consent to
the reproduction and distribution of these guidelines for educational purposes. Address correspondence to: Joseph Godges, DPT, ICF Practice Guidelines Coordinator,
Orthopaedic Section, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: icf@orthopt.org

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Adhesive Capsulitis: Clinical Practice Guidelines

Recommendations

PATHOANATOMICAL FEATURES: Clinicians should assess for im- Shoulder and Elbow Surgeons shoulder scale (ASES), or
pairments in the capsuloligamentous complex and musculo- the Shoulder Pain and Disability Index (SPADI). These
tendinous structures surrounding the shoulder complex when should be utilized before and after interventions intended
a patient presents with shoulder pain and mobility deficits to alleviate the impairments of body function and structure,
(adhesive capsulitis). The loss of passive motion in multiple activity limitations, and participation restrictions associated
planes, particularly external rotation with the arm at the side with adhesive capsulitis. (Recommendation based on strong
and in varying degrees of shoulder abduction, is a significant evidence.)
finding that can be used to guide treatment planning. (Rec-
ommendation based on theoretical/foundational evidence.) EXAMINATION – ACTIVITY LIMITATION MEASURES: Clinicians
should utilize easily reproducible activity limitation and
RISK FACTORS: Clinicians should recognize that (1) patients participation restriction measures associated with their
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with diabetes mellitus and thyroid disease are at risk for patient’s shoulder pain to assess the changes in the patient’s
developing adhesive capsulitis, and (2) adhesive capsulitis level of shoulder function over the episode of care. (Recom-
is more prevalent in individuals who are 40 to 65 years of mendation based on expert opinion.)
age, female, and have had a previous episode of adhesive
capsulitis in the contralateral arm. (Recommendation based EXAMINATION – PHYSICAL IMPAIRMENT MEASURES: Clini-
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

on moderate evidence.) cians should measure pain, active shoulder range of motion
(ROM), and passive shoulder ROM to assess the key impair-
CLINICAL COURSE: Clinicians should recognize that adhesive ments of body function and body structures in patients with
capsulitis occurs as a continuum of pathology characterized adhesive capsulitis. Glenohumeral joint accessory motion
by a staged progression of pain and mobility deficits and may be assessed to determine translational glide loss. (Rec-
that, at 12 to 18 months, mild to moderate mobility deficits ommendation based on theoretical/foundational evidence.)
and pain may persist, though many patients report minimal
to no disability. (Recommendation based on weak evidence.) INTERVENTION – CORTICOSTEROID INJECTIONS: Intra-articular
corticosteroid injections combined with shoulder mobil-
Journal of Orthopaedic & Sports Physical Therapy®

DIAGNOSIS/CLASSIFICATION: Clinicians should recognize that ity and stretching exercises are more effective in providing
patients with adhesive capsulitis present with a gradual short-term (4-6 weeks) pain relief and improved function
and progressive onset of pain and loss of active and passive compared to shoulder mobility and stretching exercises
shoulder motion in both elevation and rotation. Utilizing alone. (Recommendation based on strong evidence.)
the evaluation and intervention components described in
these guidelines will assist clinicians in medical screening, INTERVENTION – PATIENT EDUCATION: Clinicians should utilize
differential evaluation of common shoulder musculoskeletal patient education that (1) describes the natural course of
disorders, diagnosing tissue irritability levels, and planning the disease, (2) promotes activity modification to encourage
intervention strategies for patients with shoulder pain and functional, pain-free ROM, and (3) matches the intensity of
mobility deficits. (Recommendation based on expert opinion.) stretching to the patient’s current level of irritability. (Rec-
ommendation based on moderate evidence.)
DIFFERENTIAL DIAGNOSIS: Clinicians should consider diag-
nostic classifications other than adhesive capsulitis when INTERVENTION – MODALITIES: Clinicians may utilize short-
the patient’s reported activity limitations or impairments wave diathermy, ultrasound, or electrical stimulation
of body function and structure are not consistent with the combined with mobility and stretching exercises to reduce
diagnosis/classification section of these guidelines, or when pain and improve shoulder ROM in patients with adhesive
the patient’s symptoms are not resolving with interventions capsulitis. (Recommendation based on weak evidence.)
aimed at normalization of the patient’s impairments of body
function. (Recommendation based on expert opinion.) INTERVENTION – JOINT MOBILIZATION: Clinicians may utilize
joint mobilization procedures primarily directed to the
EXAMINATION – OUTCOME MEASURES: Clinicians should use glenohumeral joint to reduce pain and increase motion and
validated functional outcome measures, such as the Disabili- function in patients with adhesive capsulitis. (Recommenda-
ties of the Arm, Shoulder and Hand (DASH), the American tion based on weak evidence.)

a2 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy

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Adhesive Capsulitis: Clinical Practice Guidelines

Recommendations (continued)

INTERVENTION – TRANSLATIONAL MANIPULATION: Clinicians INTERVENTION – STRETCHING EXERCISES: Clinicians should
may utilize translational manipulation under anesthesia instruct patients with adhesive capsulitis in stretching exer-
directed to the glenohumeral joint in patients with adhesive cises. The intensity of the exercises should be determined by
capsulitis who are not responding to conservative interven- the patient’s tissue irritability level. (Recommendation based
tions. (Recommendation based on weak evidence.) on moderate evidence.)

Introduction
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AIM OF THE GUIDELINES ally accepted terminology, of the practice of orthopaedic
The Orthopaedic Section of the American Physical Ther- physical therapists
apy Association (APTA) has an ongoing effort to create • Provide information for payers and claims reviewers re-
evidence-based practice guidelines for orthopaedic physi- garding the practice of orthopaedic physical therapy for
cal therapy management of patients with musculoskeletal common musculoskeletal conditions
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

impairments described in the World Health Organization’s • Create a reference publication for orthopaedic physical
International Classification of Functioning, Disability and therapy clinicians, academic instructors, clinical instruc-
Health (ICF).137 tors, students, interns, residents, and fellows regarding the
best current practice of orthopaedic physical therapy
The purposes of these clinical guidelines are to:
• Describe evidence-based physical therapy practice, includ- STATEMENT OF INTENT
ing diagnosis, prognosis, intervention, and assessment of These guidelines are not intended to be construed or to serve
outcome, for musculoskeletal disorders commonly man- as a standard of medical care. Standards of care are deter-
aged by orthopaedic physical therapists mined on the basis of all clinical data available for an individ-
Journal of Orthopaedic & Sports Physical Therapy®

• Classify and define common musculoskeletal conditions us- ual patient and are subject to change as scientific knowledge
ing the World Health Organization’s terminology related to and technology advance and patterns of care evolve. These
impairments of body function and body structure, activity parameters of practice should be considered guidelines only.
limitations, and participation restrictions Adherence to them will not ensure a successful outcome in
• Identify interventions supported by current best evidence every patient, nor should they be construed as including all
to address impairments of body function and structure, ac- proper methods of care or excluding other acceptable meth-
tivity limitations, and participation restrictions associated ods of care aimed at the same results. The ultimate judgment
with common musculoskeletal conditions regarding a particular clinical procedure or treatment plan
• Identify appropriate outcome measures to assess changes must be made in light of the clinical data presented by the
resulting from physical therapy interventions in body func- patient and the diagnostic and treatment options available.
tion and structure as well as in activity and participation of However, we suggest that significant departures from accept-
the individual ed guidelines should be documented in the patient’s medical
• Provide a description to policy makers, using internation- records at the time the relevant clinical decision is made.

journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a3

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outcome measures.48 as modified by MacDermid also acknowledged by the Orthopaedic Section. This must include at least (1966 through September 2011) for any relevant articles related 1 level I study to classification. ICF-based clinical practice guidelines. In this modified system. These guidelines will be considered Conflicting Higher-quality studies conducted on for review in 2017. For personal use only. and the Cochrane Database of Systematic Reviews A dation. their reference lists were hand searched in an at. level II studies support the recommen- Journal of Orthopaedic & Sports Physical Therapy® CINAHL. It was lines described by Guyatt et al. B evidence trolled trial or a preponderance of level and intervention strategies for shoulder adhesive capsulitis II studies support the recommendation and frozen shoulder. The recommendation is be noted on the Orthopaedic Section of the APTA website: based on these conflicting studies www. as most of the evidence associated with changes in levels of impairment or function GRADES OF RECOMMENDATION in homogeneous populations is not readily searchable using BASED ON STRENGTH OF EVIDENCE the ICD terminology. III Case-controlled studies or retrospective studies rize patients into mutually exclusive impairment patterns upon IV Case series which to base intervention strategies.orthopt. ance of level III and IV studies.org at on May 7. The GRADES OF EVIDENCE second task given to the content experts was to describe inter- Downloaded from www. APTA as developers and authors of clinical practice guidelines I prospective studies. described using ICF terminology. These guidelines were by content experts. examination. UK (http://www. based on publications in the scientific literature recommendation prior to September 2011. Any updates to these guidelines in the interim period will D conclusions.cebm. These content experts prospective studies. 2014. or randomized controlled trials for musculoskeletal conditions of the shoulder that are com. C including statements of consensus tempt to identify other relevant articles. and (2) serve as measures V Expert opinion of changes in function over the course of an episode of care. Additionally. and intervention for musculo­ Moderate A single high-quality randomized con- skeletal conditions related to classification.net) for diagnostic. less than 80% follow-up) and structure. this conclusion Oxford.org. that could (1) catego.100 An abbreviated version of the F clinical experience of the guidelines development team grading system is provided as follows. C. a4 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines. II were given the task of identifying impairments of body function weaker diagnostic criteria and reference standards. Thus. and therapeutic studies. when relevant articles were Weak evidence A single level II study or a preponder- identified. The overall strength of the evidence supporting recommenda- ventions and supporting evidence for specific subsets of pa- tions made in these guidelines was graded according to guide- tients based on the previously chosen patient categories. Expert opinion Best practice based on the tive. prospec. no blinding. the typical A. monly treated by physical therapists. B. from LEVELS OF EVIDENCE E evidence conceptual models/principles. Theoretical/ A preponderance of evidence from foundational animal or cadaver studies. or sooner if new evidence becomes avail- evidence this topic disagree with respect to their able. Evidence obtained from high-quality diagnostic studies. or randomized controlled trials (eg. Evidence obtained from lesser-quality diagnostic studies. or from Individual clinical research articles were graded according to basic science/bench research supports criteria described by the Centre for Evidence-Based Medicine. APTA content et al73 and adopted by the coordinator and reviewers of this experts that only performing a systematic search and review of Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. the authors of these guidelines Strong evidence A preponderance of level I and/or independently performed a systematic search of MEDLINE.indd 4 4/17/2013 3:58:23 PM . support the issued in 2013. and participation restric- tions. im- proper randomization.jospt. No other uses without permission. Adhesive Capsulitis: Clinical Practice Guidelines Methods Content experts were appointed by the Orthopaedic Section. and D the evidence related to diagnostic categories based on Interna- grades of evidence have been modified to include the role of tional Statistical Classification of Diseases and Related Health consensus expert opinion and basic science research to dem- Problems (ICD)136 terminology would not be sufficient for these onstrate biological or biomechanical plausibility. activity limitations. project.

0. The corresponding ICD-9-CM code. journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a5 43-05 Guidelines. d6402 cleaning living area. with self-care.0. APTA also selected consultants cuff. Comments from these reviewers were utilized by the authors Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. • Claims review • Coding The ICD-10 code associated with adhesive capsulitis is • Epidemiology M75. No other uses without permission. d4454 throwing. mobility deficits. 2014.jospt. proximal humeral fracture. because it is the term used in drafts of these clinical practice guidelines: the ICD. and d9201 sports. d6201 gathering Journal of Orthopaedic & Sports Physical Therapy® sulitis and secondary adhesive capsulitis related to systemic daily necessities. d5401 taking off clothes. d4551 climbing. • Physical therapy academic education mobility of a single joint. d5101 wash- guidelines to describe both primary idiopathic adhesive cap. is 726. d6600 assisting others well as extrinsic or intrinsic factors. as taining dwelling and furnishings. • Orthopaedic physical therapy residency education • Orthopaedic physical therapy clinical practice The primary ICF body function codes associated with shoul- • Orthopaedic surgery der pain and mobility deficits/adhesive capsulitis are b28014 • Rheumatology pain in the upper limb.org at on May 7. such as diabetes mellitus and thyroid disorders. The term adhesive capsulitis is used. and periar. from the following areas to serve as reviewers of the early rather than frozen shoulder. d4302 thritis have been used for patients with shoulder pain and carrying in the arms. or labral pathology. and b7100 Downloaded from www. d2303 completing the daily routine. b28016 pain in joints. commonly used • Medical practice guidelines in the United States. d4300 lifting. For personal use only. d5400 putting on clothes. d5100 washing body parts. d6501 main- disease. Adhesive capsulitis will be used in these d4554 swimming. ing whole body. to edit these clinical practice guidelines prior to submitting The primary ICF activities and participation codes associated them for publication to the Journal of Orthopaedic & Sports with adhesive capsulitis are d4150 maintaining a lying posi- Physical Therapy. frozen shoulder. The secondary ICF activities and CLASSIFICATION participation codes associated with adhesive capsulitis are The terms adhesive capsulitis. d5202 caring for hair. The primary ICF body structure • Sports physical therapy/rehabilitation clinical practice codes associated with adhesive capsulitis are s7201 joints • Sports physical therapy residency education of shoulder region and s7203 ligaments and fasciae of shoulder region. tion. Adhesive Capsulitis: Clinical Practice Guidelines Methods (continued) REVIEW PROCESS cular accident. and d4452 reaching. including cerebral vas. causative rotator The Orthopaedic Section.indd 5 4/17/2013 3:58:24 PM . All rights reserved.

126.99 restricts external rotation while the posterior limb restricts internal rotation.134. but the rotator cuff interval and spe- rior to the lesser tuberosity and surgical and anatomic necks).86 inflammation of the long head of the scapularis were found to limit external rotation when the biceps tendon and its synovial sheath.55.17. cifically the capsuloligamentous complex are predominantly from the coracoid and glenoid rim via the labrum and gle.28.88.7%) and men (38.3% and 38%. 55.102 The rota- diabetes mellitus and thyroid disease is reported to be be.7  8. With the arm at the side. Adhesive Capsulitis: Clinical Practice Guidelines CLINICAL GUIDELINES Impairment/Function-Based Diagnosis PREVALENCE The rotator cuff interval forms a triangular-shaped The prevalence of shoulder pain has been reported to be be- tween 2.94.71.1% versus 7.55.0  8. vial membrane lining the interior joint capsule and encasing the long head of the biceps tendon into the biceps groove.97 Milgrom et al77 compared 126 humeral ligament and the coracohumeral ligament.133 yet focal vascularity and synovial an- women (21.94.83.5.77 there is evidence of new nerve growth in the capsuloligamen- tous complex of patients with adhesive capsulitis. patients (76 women. For personal use only.84. significant The glenohumeral joint is a synovial joint containing a syno.92. population. The Significant capsuloligamentous complex fibrosis glenohumeral capsule.0% versus 6.36.jospt. giogenesis (increased capillary growth) rather than synovitis sulitis was found compared to the age-matched regional are described by others.82. patients with adhesive capsulitis resulted in a dramatic in- II ence of the subscapularis and selected capsulo- ligamentous complex portions. type 1 or 2. consistent with inflamma- tion.44 E capsuloligamentous complex and musculotendi- nous structures surrounding the shoulder complex a6 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines.51. mean  SD age. was not identified. The entire capsuloligamentous complex the glenohumeral joint inserting onto the humerus (supe. The capsuloligamentous complex and rotator cuff of the anterosuperior complex.135 Accompanying angiogenesis. (23. 54. This complex surrounds logic examination.69 Primary adhesive capsulitis is re- II tissue bridge between the anterior supraspinatus tendon edge and the upper subscapularis border. the anterosuperior capsule was found to have not men. subscapular recess.83. coracohumeral ligament.org at on May 7. mean  SD age. the anterior limb sleeve around the glenohumeral joint. the previously unrecognized posterosuperior glenohumeral cantly higher prevalence of diabetes among both women ligament. 50 Recently.82. No other uses without permission.71. 95.55.9%) with idiopathic adhesive cap. tor cuff interval is primarily composed of the superior gleno- tween 4.49 Regardless of the sy- Journal of Orthopaedic & Sports Physical Therapy® PATHOANATOMICAL FEATURES novial pathology being angiogenesis or synovitis. which may explain the heightened pain response.125 The proximal crease in shoulder external rotation motion. middle.7 years) with idiopathic only an anterior limb but also a posterior limb containing adhesive capsulitis to prevalence data and found a signifi.4% and 26%.134 The rotator cuff interval is part noid neck.63. The type of diabetes.71. It has been Clinicians should assess for impairments in the suggested that a greater loss of external rotation at 45° versus 90° of abduction indicates subscapularis restriction.96 Others have noted significant subacromial scarring.127.50.3% of the general population.5%) with adhesive capsulitis as compared to the age-matched popu. ported to affect 2% to 5.17.85 loss of the portion of the capsuloligamentous complex and the sub.25. can become fibrotic. All rights reserved.92.103 Coracohumeral ligament release in Cadaver studies demonstrate the restricting influ.7. 2014.133 and musculotendi- glenohumeral joint was positioned up to 45° of abduction.5. pain can result at rest or with motion. and inferior) comprise IV and contracture are consistently observed upon open or arthroscopic shoulder surgery and histo- the capsuloligamentous complex. Adhesive capsulitis is marked by the presence of lation.indd 6 4/17/2013 3:58:24 PM .4 years.50.29. A significantly higher prevalence of hypothyroidism among IV multiregional synovitis.85 Turkel et al125 found that the subscapularis limited external rotation the most with the arm at 0° of abduction. nous contracture. and gleno- humeral ligaments (superior.103 Downloaded from www.96. involved. which functions as a supe- tendons create an intimate static and dynamic constraining rior hammock.97 with the apex located on the biceps sulcus lateral ridge at The prevalence of secondary adhesive capsulitis related to the margin of the transverse humeral ligament.7% versus 4.20.103 Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®.

an inability to lie on capsulitis is more prevalent in individuals who are 40 to 65 the affected side. and adhesive capsulitis can occur bilaterally simultaneously Journal of Orthopaedic & Sports Physical Therapy® year period.org at on May 7.5.9%).83.9% of the controls.113 To date.20. arthroscopic examination reveals diffuse group (12. age. Recent evidence implicates elevated serum Cakir et al22 performed physical examinations on cytokine levels as causing or resulting in a sustained intense and protracted inflammatory/fibrotic response affecting the II 137 patients (111 females. In addition.50. diabetes duration.71.45. The loss of passive motion in multiple planes. The in.0 (95% CI: 3. Other associated risk factors include prolonged im- as indicated by the risk ratios of 5. Aydeniz et al5 compared 102 patients (mean  SD Four stages of adhesive capsulitis.indd 7 4/17/2013 3:58:25 PM .3 (95% CI: 4.50. Additionally. and have had a previous episode of ad- motion in 3 or more planes.50.71. particularly external rotation with the arm II adhesive capsulitis.20 monly than males. hesive capsulitis in the contralateral arm.5) in women. associated with thyroid disease.21.1 years) with type 2 diabetes mellitus to an age.6%. tween cytokines and the causative factor.77.7 II risk factors associated with idiopathic adhesive capsulitis by comparing the prevalence of diabetes Having adhesive capsulitis on 1 side places an individual at risk (5%-34%) for opposite-arm involvement in the future.7%) versus the control group (3. 7.97 Females appear to be affected more com- incidence of primary adhesive capsulitis. IV mobilization. 58. Adhesive capsulitis was associated with age (mean  SD. 11.89 Early loss of external rota- journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a7 43-05 Guidelines. with the reported peak incidence occurring.jospt. ranges of motion. Milgrom et al77 reported an increased prevalence of thyroid dysfunction in patients with adhesive capsulitis com- pared to an age-matched regional population. and sleep disturbance. mal to no ROM restrictions.3% had diabetes mel. nificant relationship between adhesive capsulitis and Dupuy- tren’s contracture.22 ous or related to minor trauma. and autoimmune disease.84. Dupuytren’s contracture. compared to 3. both Dupuytren’s with adhesive capsulitis. III been identified. is unknown. achy pain at rest. myocardial infarction. The prevalence of synovial lining and capsuloligamentous complex in patients adhesive capsulitis was 10.78. reflecting a continuum. 8. No other uses without permission. between 51 type 1 diabetes mellitus for 10 or more years have a greater and 55. 2014.9 (95% confidence interval [CI]: 4.4) in men and 5. The majority of the patients with thyroid is a significant finding that can be used to guide treatment disease who developed adhesive capsulitis were women (16 planning.120 However.24 years) and the duration of CLINICAL COURSE diabetes.4% of patients with adhesive capsulitis had thy- at the side and in varying degrees of shoulder abduction.9%. Age can be considered a risk factor because ad- Individuals with type 1 or 2 diabetes mellitus have II hesive capsulitis more commonly occurs in indi- Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®.7. Milgrom et al77 reported that 13. identified litis in an identified group of patients with diabetes mellitus. in new cases (n = 126) to age-matched controls over a 2. 17. 26 males) with hyper- thyroidism or hypothyroidism.9%) had adhesive capsu- Milgrom et al.83.5. trauma.6 Although the etiology of adhesive capsulitis has not (95% CI: 0.6%) than females (25. as demonstrat- RISK FACTORS ed by risk ratios of 7.140 Balci et al7 evaluated patients with type 2 diabetes mellitus (n = 297.9%) had adhesive capsulitis. and (2) adhesive having at least 1 month of shoulder pain. and restricted active and passive shoulder years of age.7% had and during this stage patients describe sharp pain at end adhesive capsulitis. as defined by B diabetes mellitus and thyroid disease are at risk for developing adhesive capsulitis.1) in women and 2.104. roid dysfunction.8%) and carpal tunnel syndrome (9.89 Stage 1 may last up to 3 months. Patients with adhesive capsulitis had a higher rate of diabetes mellitus compared to an age-matched population. there are a number of associated factors. they found a sig. of 17).54. and sex-matched control group and found that 14.0) in men.5.4. female. III a greater propensity of developing adhesive capsu- litis. have been described. For personal use only.97 Patients with Dupuytren’s disease or viduals between 40 and 65 years of age. Adhesive Capsulitis: Clinical Practice Guidelines when a patient presents with shoulder pain and mobility Thyroid disease is a risk factor associated with deficits (adhesive capsulitis). a greater proportion of males (33.87.7. whether it is insidi. 59.23  8.77 in a prospective study. clinical diagnosis early in this stage because there are mini- trigger finger).5%) were Downloaded from www. and Subacromial shoulder impingement is often the suspected musculoskeletal complications (ie. on average. up to 14% of the time.0  9. 29.119 litus.12.77. the relationship be.18. All rights reserved.18. There were synovial reaction without adhesions or contracture.71. cidence of Dupuytren’s contracture was higher in the diabetic During this stage.3. Of the 126 new cases. contracture (8.1. 33.111. women.16. 60% female) to determine the presence of adhesive Clinicians should recognize that (1) patients with capsulitis and other conditions.89.8. They found that 29% (men.83.89 significant associations between age. 25.

45. globally limited glenohumeral joint translation. shoulder test (SST) and the DASH. known as the “painful” or “freezing” stage. an inability to lie on the affected shoulder. 4. The Medical Outcomes Study 36-Item minimum of 3 years after the diagnosis. the synovitis/angiogenesis lessens male gender were related to worse ROM outcomes. and less than 50% of external rotation may have a protracted recovery and worse outcomes. ROM did aggressive synovitis/angiogenesis and some loss of motion not correlate with patient-rated outcome scores on the simple under anesthesia. This stage often progresses to pain resolution. 2014. No difference in recovery was seen between IV ria for stage 2 adhesive capsulitis. fore. For personal use only. the ASES.90 tion and/or capsular release. There- abducted at 90°.jospt. The average duration of treatment was concluded that at a long-term follow-up (mean. and the time of diagnosis. Seven but the progressive capsuloligamentous fibrosis results in loss percent of the patients were eventually treated with manipu- of the axillary fold and ROM when tested under anesthe.7  13.19.119 Patients with diabetes mellitus of abduction or less. However. sleep disturbance due did not correlate with functional deficits.6 gradual loss of motion in all directions due to pain and can points on the DASH questionnaire (range of score from 0 to last from 3 to 9 months. nonsteroidal anti-inflammatory drugs. and the SST patients.89 Stage 3.7 months.83 Stage with their outcome. is character. They impairment measure. the patients had a history of no or only trivial shoulder patients with diabetes mellitus and those without diabetes. The authors noted that at 6 months and at a 4 shoulder surgeons. but motion restrictions may persist that are unchanged even when exam. ROM loss had shoulder pain for at least 1 month. had not regained normal ROM when were used as patient-rated outcome measures. restriction Journal of Orthopaedic & Sports Physical Therapy® in all active and passive shoulder movements.45 when compared to the contralateral shoulder. pain at the extremes of all shoulder mo. A history of sia. 89% of patients had no functional deficits. during the course of nonoperative treatment.83. The investiga- tors did not state whether the 50% loss of external rotation IV patients (105 shoulders) with the diagnosis of idio- pathic adhesive capsulitis. with 0 representing no disability). trauma.89 Stage 4. and their ROM continued to decrease normal glenohumeral joint radiographic findings.37. depending on the extent of fibroplasia and subse. The vast majority of patients (90%) were satisfied adhesive capsulitis and may be seen in this stage.11. 90% and 40% of the Short-Form Health Survey (SF-36). ined under anesthesia. At an average of a 7-year follow- II 40) on patients with adhesive capsulitis. Adhesive Capsulitis: Clinical Practice Guidelines tion motion with an intact rotator cuff is a hallmark sign of capsulitis.and sex-matched control group.89 IV with adhesive capsulitis (n = 62) who were treated conservatively. All rights reserved. The criteria for inclusion were a Although adhesive capsulitis was initially considered a 12.50.31. known as the “thawing” stage.50. However. to pain. Arthroscopy reveals capsuloligamen- tous complex fibrosis and receding synovial involvement. In an average of 6 months.89. but pain with activity rat- is characterized by pain and loss of motion and lasts from 9 ing did correlate with functional loss. Arthroscopic examination reveals 100. bination of the 3. respectively. those who required surgery had less shoulder ROM at tions. pain resolved and motion returned to normal or Binder et al11 performed a prospective study (n = within 10° to 15° of normal. mild symptoms may persist no other cause could be identified. Shaffer et al119 retrospectively examined patients Downloaded from www. measurable mobility deficits persisted but patients had little Symptoms resolved in 89. Diabetes mellitus and to 15 months. documented restriction Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. aged with physical therapy. lation under anesthesia and/or capsular release. The criteria for inclusion was compared to established norms or compared to the unin. and ROM as the compared to an age.50. with an average  SD score of 9. Less than half (40%) reported residual 2. were diagnosis of adhesive capsulitis and treatment by 1 of volved extremity.83. but significant stiffness litigation was associated with being treated with manipula- persists from 15 to 24 months after onsets of symptoms. of passive glenohumeral and scapulothoracic motion of 100° quent resorption. known as the “frozen” stage.org at on May 7. and at least a Levine et al68 performed a retrospective review of 98 50% reduction in external rotation motion. In stage 3. for years.5% of the patients who were man- functional deficits. prior rehabilitation and workers’ compensation or pending ized by pain that begins to resolve. 44 months). In addition. vestigators found that 27% of these 75 patients continued to have mild pain with activity and that all patients demon. No other uses without permission. but 50% con- tinued to report mild pain or stiffness. loss of active and passive shoulder ROM (more than with this group demonstrating greater loss of elevation and ex- a 50% loss of external rotation).30. especially with the shoulder ternal rotation ROM both initially and preoperatively.83.indd 8 4/17/2013 3:58:26 PM .to minimum of 1 month of shoulder pain and stiffness for which 18-month self-limited process. intra-articular corticosteroid injections. The in. Patients were classified as having adhesive capsulitis if they up. Ten percent of the patients required operative management.1% of the patients had diabetes mellitus. and 18. Clinicians should recognize that adhesive capsulitis strated mobility deficits compared to their uninvolved side at an average of 22 months following the onset of adhesive C occurs as a continuum of pathology characterized by a staged progression of pain and mobility defi- a8 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines. or some com- Griggs et al45 assessed 75 patients who fit the crite. presents with a shoulder disability.

Intrin- sic secondary adhesive capsulitis describes patients with a • E valuation/Intervention Component 1: medical screening known pathology of the glenohumeral joint soft tissues or • Evaluation/Intervention Component 2: differential evalu- structures. acromioclavicular or glenohu. using the following components: extremity fracture. tors.61. such as rotator cuff tendinopathy. Thus. Furthermore. calcific tendinitis. Adhesive Capsulitis: Clinical Practice Guidelines cits and that.66. likely sleep-disturbing night pain found when objective measurements are taken. III tion of shoulder pain is to direct intervention and inform prognosis. myocardial infarction and chronic proposed model for diagnosis. This model is depicted in the FIGURE. though many patients report Patients with adhesive capsulitis present with a minimal to no disability. A proposed classification scheme140 suggests that primary such as impingement signs and the Jobe test.132 The capsular pat- V associated with primary or secondary adhesive cap- sulitis is determined from the history and physical tern described by Cyriax. and intrinsic. there is a lack of evidence with egies for shoulder pain and mobility deficits regard to their ability to drive treatment decision making and to prognosticate outcome. as they reproduce pain because they involve Journal of Orthopaedic & Sports Physical Therapy® tion or history of injury. which examination.106. testing. strength and painless responses to resisted tests. intra-abdominal condi.121 and external rotators. at 12 to 18 months. Systemic secondary adhesive A medical diagnosis of adhesive capsulitis may capsulitis includes those patients with a history of diabetes mellitus and thyroid disease.org at on May 7. Traditionally. and treatment obstructive pulmonary disease).58.119. No other uses without permission.12. is not consistently progressive onset of pain. biceps tendi. A consistent tivities such as reaching overhead. journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a9 43-05 Guidelines. mild to moderate mobility Classification deficits and pain may persist. such as with a cerebral vascular accident. by a loss of abduction and internal rotation. For personal use only. however.66. An impairment-based classification is neces- related to the shoulder. chronic liver disease).58. or proximal humeral or scapular tissue pathology/disease (ICD) fracture.indd 9 4/17/2013 3:58:27 PM .45.66 elevators.110. • Evaluation/Intervention Component 4: intervention strat- retical framework. impairments of body functioning (ICF) and the associated meral joint arthropathy.jospt. All rights reserved. however.82. Patients also present et al116 found varying patterns of restriction in patients with with painful and restricted active and passive ROM in both adhesive capsulitis. • Evaluation/Intervention Component 3: diagnosis of tissue ated with postoperative stiffness should not be considered irritability level adhesive capsulitis.140 Loss of shoulder ROM and pain that is associ.50 Generally. yet it results in a painful and stiff sary to guide rehabilitation. the current guidelines include a thoracic conditions (eg. ROM loss of greater than 25% DIAGNOSIS/CLASSIFICATION in at least 2 planes and passive external rotation loss that is greater than 50% of the uninvolved shoulder or less than Diagnosis 30° of external rotation have been used to define adhesive The diagnosis of shoulder pain and mobility deficits capsulitis.23.121 specifically weakness of the internal rota- atic tissue(s) and distinguish among various pathologies. These categorizations present a theo. Extrinsic secondary adhesive V be helpful in describing the tissue pathology. a patho- others have described patients with adhesive capsulitis as having reduced shoulder muscle strength with isometric anatomic model has been used to identify the symptom. Special tests. classification system. Rundquist and pain at end ranges of movements.116 Cyriax37 de- Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. examination. or self-imposed immobilization. behind the back. between a disease or pathology with 3 subcategories: sys- temic.20.11 Functional ac. are not help- frozen shoulder and idiopathic adhesive capsulitis are con. Patients typically present with a gradual and is more limited than internal rotation. secondary adhesive end-range positioning of the painful and stiff capsuloliga- capsulitis or frozen shoulder is defined by a relationship mentous complex. 37 where external rotation motion loss is proportionally greater than loss of abduction. but the most common pattern was a elevation and rotation that occurs for at least 1 month and loss of external rotation with the arm at the side followed Downloaded from www.19. planning for patients with shoulder pain and mobility defi- tions (eg.37. ful in differentiating adhesive capsulitis from rotator cuff sidered identical and not associated with a systemic condi. but most characteristi- cally have a global loss of both active and passive shoulder ROM. 2014. distal cits. However.85. possible to 90° of frontal plane abduction. scribed patients with adhesive capsulitis as having normal The primary purpose for diagnosis/classifica. but it does not aid in treatment decision making for capsulitis includes patients whose pathology is not directly rehabilitation. extrinsic. V number of impairments. intra. tendinopathy. has either reached a plateau or worsened.131. cervical disc disease. or out finding was a greater loss of internal rotation versus ex- to the side become increasingly difficult due to pain and/or ternal rotation when the arm was positioned as close as stiffness. ation of clinical findings suggestive of musculoskeletal nopathy. there is no published shoulder.

• Apprehension at end ranges of flexion. and/or external • Manual resistive tests to the rotator • Glenohumeral external or internal rotation cuff muscles. • History of shoulder dislocation the shoulder dressing. and reaching activities • Excessive glenohumeral accessory • Midrange (about 90°) catching • Glenohumeral passive range of motion motions in multiple directions sensation/arc of pain with active (ROM) is limited in multiple directions. performed in midranges rotation ROM decreases as the humerus Rule out if: of shoulder flexion and abduction. No other uses without permission. • Patient’s age is between 40 and 65 years shoulder joint • Symptoms developed from.jospt. and Rule out if: biceps brachii have normal strength • Passive ROM is normal • Significant loss of passive motion • Radiographic evidence of glenohumeral arthritis is present • Passive glenohumeral external or internal rotation ROM increases as the humerus is abducted from 45° toward 90° and the reported shoulder pain is reproduced with palpatory provocation of the subscapularis myofascia • Upper-limb nerve tension testing reproduces the reported symptoms and shoulder pain can be increased or decreased with altering nerve tension positions • Shoulder pain is reproduced with palpatory provocation of the relevant peripheral nerve entrapment site Figure continued on page A11 a10 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines. elevation more particularly in adduction horizontal abduction. repetitive overhead activities or progressive worsening of pain and stiffness • Patient’s age is less than 40 years from an acute strain such as a fall onto • Pain and stiffness limit sleeping. Diagnostic Classification Criteria Shoulder pain and mobility Shoulder stability and movement Shoulder pain and muscle power deficits/adhesive capsulitis coordination impairments/dislocation of deficits/rotator cuff syndrome Rule in if: shoulder joint. Journal of Orthopaedic & Sports Physical Therapy® is abducted from 45° toward 90° • No history of dislocation reproduce the patient’s reported • Passive motions into the end ranges of • Presence of global glenohumeral shoulder pain glenohumeral motions reproduce the • Rotator cuff muscle weakness motion limitations patient’s reported shoulder pain • Joint glides/accessory motions are • No apprehension with end-range Rule out if: restricted in all directions shoulder active or passive motions • Resistive tests are pain free • Supraspinatus.org at on May 7. 2014. grooming. with external rotation the most limited. For personal use only. All rights reserved. infraspinatus. or sprain and strain of Rule in if: Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Adhesive Capsulitis: Clinical Practice Guidelines Evaluation/Intervention Component 1: medical screening Appropriate for physical therapy Appropriate for physical therapy Not appropriate for physical versus versus evaluation and intervention evaluation and intervention along therapy evaluation and intervention with consultation with another healthcare provider Evaluation/Intervention Component 2: differential Consultation with appropriate evaluation of clinical findings suggestive of healthcare provider musculoskeletal impairments of body functioning (ICF) and the associated tissue pathology/disease (ICD) Downloaded from www. or worsen • Patient reports a gradual onset and Rule in if: with.indd 10 4/17/2013 3:58:27 PM .

rather than from a common shoulder and physical examination to determine whether the patient’s musculoskeletal disorder. progressing the procedures in the pain-free accessory procedures. progressing the intensity movement during performance of the and duration of the stretches into activities performed by the patient tissue resistance without producing during his/her functional and/or posttreatment tissue inflammation recreational activities and associated pain Neuromuscular re-education: • Procedures to integrate gains in mobility into normal scapulohumeral movement while performing reaching activities Component 1 symptoms originate from a more serious pathology. Adhesive Capsulitis: Clinical Practice Guidelines Evaluation/Intervention Component 3: diagnosis of tissue irritability level High Irritability Moderate Irritability Low Irritability Characterized by: Characterized by: Characterized by: • Reports high levels of pain • Reports moderate levels of pain • Reports minimal levels of pain (≥7/10) (4-6/10) (≤3/10) • Consistent night or resting pain • Intermittent night or resting pain • No night or resting pain • High levels of reported disability versus • Moderate levels of reported versus • Minimal levels of reported on standardized self-report disability on standardized disability on standardized outcome tools self-report outcome tools self-report outcome tools • Pain occurs before end ranges of • Pain occurs at end ranges of • Pain occurs with overpressures active or passive movements active or passive movements into end ranges of passive • Active ROM is significantly less • Active ROM similar to passive ROM movements than passive ROM due to pain • Active ROM same as passive ROM Downloaded from www. Evaluation/Intervention Component 4: intervention Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. For personal use only.jospt.org at on May 7. such as Medical screening incorporates the findings of the history a tumor or infection.139 In addition to serious medi- journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a11 43-05 Guidelines. progressing amplitude duration of the stretches into tissue ranges and glenohumeral positions and duration of procedures into tissue resistance without producing Mobility exercises: resistance without producing posttreatment tissue inflammation and • Pain-free passive ROM exercises posttreatment tissue inflammation associated pain • Pain-free active assisted ROM and associated pain Neuromuscular re-education: exercises Stretching exercises: • Procedures to integrate gains in • Gentle to moderate stretching mobility into normal scapulohumeral exercises. high amplitude and long Journal of Orthopaedic & Sports Physical Therapy® comfort and activity modifications to without producing tissue inflammation duration of procedures into tissue limit tissue inflammation and pain and pain resistance Manual therapy: Manual therapy: Stretching exercises: • Low-intensity joint mobilization • Moderate-intensity joint mobilization • Stretching exercises. All rights reserved.indd 11 4/17/2013 3:58:28 PM . No other uses without permission.80. strategies for shoulder pain and mobility deficits High Irritability Moderate Irritability Low Irritability Modalities: Modalities: Self-care/home management training: • Heat for pain modulation • Heat for pain modulation as needed • Patient education on progression to • Electrical stimulation for pain • Electrical stimulation for pain performing high-demand functional modulation modulation as needed and/or recreational activities Self-care/home management training: Self-care/home management training: Manual therapy: • Patient education on progressing • End-range joint mobilization • Patient education on positions of activities to gain motion and function procedures. 2014.

2014. secondary flammatory activity that is present. All rights reserved. and planning tients with shoulder pain often fit more than 1 impairment intervention strategies for patients with shoulder pain and pattern and that the most relevant impairments of body func. and strengthening activities. which focus on normalizing the sive physical stress in the form of stretching.60 mental health practitioner.10 Patients with a high level of tissue irritability are not ready for significant physical stress being applied to the affected tissues. are described as impairment physical stress in the form of progressive manual therapy. Irritability is a term used by rehabilitation practitioners to •  cute calcific tendonitis/bursitis A reflect the tissue’s ability to handle physical stress. Impairment-based classification is criti. Thus. and rotator cuff syndrome/tendinopathy of Component 3 the supraspinatus. No other uses without permission. only low used to determine the most relevant physical impairments as. able to perform basic functional activities. it is important for clinicians to understand that pa. and level of dis- with a longer recovery. medication. gressive onset of pain and loss of active and passive ment patterns. They should also be according to the key impairment(s) of body function associ. frequency of pain. tion and the associated intervention strategies often change during the patient’s episode of care. patients with shoulder pain. lined in the Diagnosis/Classification section of these clinical guidelines—adhesive capsulitis. For personal use only. which erate level of irritability should be able to tolerate controlled Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®.136 should be clinical decisions regarding treatment frequency. movement and function of the patient and lessens or alleviates the activity limitations commonly reported by the patients Clinicians should recognize that patients with ad- who meet the diagnostic criteria of that specific pattern. and biceps brachii—the fol- Diagnosis of tissue irritability is important for guiding the lowing conditions. For example. using ICD-10 terminology. with the goal of matching the optimal sents with shoulder pain: dosage of treatment to the status of the tissue being treated. infraspinatus. diagnosing tissue irritability levels. Differential evaluation of musculoskeletal clinical findings is therapy to relieve pain and inflammation.79 Accordingly. These impairment patterns are useful tients with low irritability should be able to tolerate progres- in driving the interventions. Adhesive Capsulitis: Clinical Practice Guidelines cal conditions. In comparison. which in turn improves the resistive exercise. disorders. The primary clinical psychosocial issues that may affect prognostication and finding that determines the level of tissue irritability is the treatment decision making for rehabilitation. mobility deficits. relation between pain and active and passive movements. and work loss in ability reported by the patient. clinicians should match the most ap- referring the patient for consultation with another medical or propriate intervention strategies to the level of irritability.indd 12 4/17/2013 3:58:28 PM . and manual Downloaded from www. and higher-demand physical activities.org at on May 7. key impairments of body function. levels of glenohumeral exercises should be performed while sociated with the patient’s reported activity limitations and encouraging motion at adjacent regions. and type. differential evaluation of common shoulder musculoskeletal However. commonly coexist in patients. intensity. Utilizing shown in the FIGURE. mild patterns in the physical therapy literature1 and are labeled stretching. and their associated medical conditions.81 and is • Arthrosis of the shoulder. Component 4 cation strategies to optimize patient outcomes to physical Because irritability level often reflects the tissue’s ability to therapy interventions and potentially provide indications for accept physical stress. Clusters of these clinical findings. considered in the differential diagnosis when a patient pre­ duration. Three levels of irritability • Bursitis of the shoulder a12 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines. clinicians should screen for the presence of are operationally defined in the FIGURE.jospt. are shoulder motion in both elevation and rotation.42. and therefore the treatment should emphasize activity modi- Component 2 fication and appropriate modalities. In addition. provide the optimal outcome for a patient’s clinical findings. elevated scores on the Tampa Scale of Kinesiophobia or the Other clinical findings that characterize the level of tissue Fear-Avoidance Beliefs Questionnaire have been associated irritability are pain level. chronic symptoms.59. continual re-eval- uation of the patient’s response to treatment and the patient’s DIFFERENTIAL DIAGNOSIS emerging clinical findings is important for providing the op. In addition to the 3 most common shoulder conditions out- timal interventions throughout the patient’s episode of care. Patients with a mod- medical diagnosis. primary presumably related to physical status and the extent of in. Key F hesive capsulitis present with a gradual and pro- Journal of Orthopaedic & Sports Physical Therapy® clinical findings to rule in and rule out the common impair. identifying cognitive behavioral tendencies during the patient’s evalua- tion can direct the therapist to employ specific patient edu. • Arthrosis of the shoulder. the evaluation and intervention components described in cal for matching the intervention strategy that is most likely to these guidelines will assist clinicians in medical screening. manual therapy. pa- ated with that cluster. sprain and strain of shoulder joint/dislocation.

1. rotator cuff • Pain in thoracic spine interval thickening.41 orders or diseases • Pyogenic arthritis A recent study64 using ultrasonography with arthroscopic • Radiculopathy confirmation identified fibrovascular inflammatory soft tis- Journal of Orthopaedic & Sports Physical Therapy® • Rheumatoid arthritis sue changes in the rotator cuff interval in 100% of 30 pa- • Somatoform autonomic dysfunction tients with adhesive capsulitis with symptoms less than 12 • Sprain and strain of acromioclavicular joint months. Homsi et al52 performed ultrasound examinations • Sprain and strain of sternoclavicular joint of the coracohumeral ligament on 306 individuals with pain- ful shoulders. joint volume reduction. and proliferative synovitis surrounding • Persistent somatoform pain disorder the coracohumeral ligament have been observed in patients • Psychological and behavioral factors associated with dis. capsulitis painful-shoulder group. Arthrographic findings associated with adhesive cap- • Fracture of scapula sulitis include a joint capsule capacity of less than 10 to • Fracture of shaft of humerus 12 mL and variable filling of the axillary and subscapular • Fracture of upper end of humerus recess. findings in- • Osteoarthritis of the acromioclavicular joint cluded a thickened coracohumeral ligament and joint capsule Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®.105 • Impingement syndrome of the shoulder • Injury of blood vessels at shoulder and upper-arm level.128 MRI has identified abnormalities of the level. • Osteoarthritis of the cervical spine in the rotator cuff interval and a smaller axillary recess vol- • Osteoarthritis of the glenohumeral joint ume. with arthrographic evidence of adhesive capsulitis. including labral lesions capsule and rotator cuff interval in patients with adhesive • Injury of nerves at shoulder and upper-arm level.71.0001) in the adhesive capsulitis group aimed at normalization of the patient’s impairments of body compared to the asymptomatic group and the non–adhesive function.and sex-matched control group.indd 13 4/17/2013 3:58:29 PM . such as glenohumeral osteoarthri- • Fracture of clavicle tis.org at on May 7. 121 asymptomatic shoulders.jospt. ax- • Osteoporosis with pathological fracture illary recess thickening. The aver- F tions other than adhesive capsulitis when the pa- tient’s reported activity limitations or impairments age thickness of the coracohumeral ligament was 3 mm in the adhesive capsulitis group.41. Coracohumeral ligament thickness was sig- the patient’s symptoms are not resolving with interventions nificantly greater (P = . or when shoulder group. For personal use only.33. and 17 shoulders Clinicians should consider diagnostic classifica.39 mm in the non–adhesive capsulitis painful- Diagnosis/Classification section of these guidelines. but without axillary recess thickening.86.34 mm in the asymptomatic of body function and structure are not consistent with the group. journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a13 43-05 Guidelines. Radiographs are • Diseases of the digestive system typically normal with adhesive capsulitis but can identify • Fibromyalgia osseous abnormalities. Using MRI. Adhesive Capsulitis: Clinical Practice Guidelines •  ervicalgia C IMAGING • Cervical disc disorders Diagnosing adhesive capsulitis is primarily determined by • Cervicobrachial syndrome history and physical examination.75 Mengiardi et al75 performed magnetic reso- Downloaded from www. Magnetic resonance imaging (MRI) may help with the dif- including avascular necrosis ferential diagnosis by identifying soft tissue and bony ab- • Injury of muscle and tendon at shoulder and upper-arm normalities. and 1. suprascapular nerve entrapment nance arthrograms on 122 patients who were treated with • Juvenile rheumatoid arthritis arthroscopic capsular release and compared the findings with • Neoplasm those of an age. All rights reserved. 2014. but imaging studies can • Contusion of shoulder and upper arm be used to rule out underlying pathology. with adhesive capsulitis. No other uses without permission.33.9. including capsulitis.

the change in scores that is considered great. The self-report sec. with 100 indicating maximum shoulder • P ain during sleep use.118 the MDC at the 95% confidence tion contains a single pain question (15 points) and 4 ques. such as the DASH.47. with 0 indicating no pain or difficulty. no disability. the ASES.122 The minimal detectable change (MDC). and participation DASH. not all have demonstrated acceptable (weighted average. the ASES. and SPADI are erature other than what is indicated for the patient self-report recommended for clinical use.112 and The SPADI112 is a 13-item patient self-report tool with 2 do- Downloaded from www.43. and SST have been the most studied shoul.indd 14 4/17/2013 3:58:30 PM . a14 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines.jospt. These tools can be clas.53. to assess patient-rated function. and 8 items of disability.72. shoulder disease specific. restrictions associated with adhesive capsulitis. The following measures can help the clinician to assess changes in the patient’s level of function over time: The ASES is a patient self-report scale that has a range of scores from 0 to 100. These should be utilized before and after interventions intended to alleviate the impairments of body Two recent systematic reviews15. for the ASES has been reported to be 9. Over 30 tools have been pub.62. The scores range from 0 to 100. 115.2 points. the ASES. All rights reserved. sleep. The measurement properties of the DASH sified as shoulder joint specific. activity limitations. behind the back.098 and (20 points).15. and scores can range from 0 to 100. report section. it is not clear if the Con- stant score items comprehensively represent the construct Clinicians should use validated functional outcome A Journal of Orthopaedic & Sports Physical Therapy® of shoulder use.2 points lished.115 The MDC at the 90% confidence level has indicating maximum use of the shoulder. and the minimal F limitation and participation restriction measures associated with their patients’ shoulder pain to as- clinically important difference has been reported to be 6. have been extensively investigated.2. 34 the DASH. Activity limitation measures have not been reported in the lit- ingful change. and position of arm use cally important difference has been reported to be 8. No other uses without permission.0.43. Measurement 13. and overhead measurement properties. been reported to be 18.115 questionnaires. function and structure. The ASES. 5 pain items.15.14.3 and the minimal clini- tions assessing work.4 points. consisting of 50 points maximum for pain (1 question) • Pain and difficulty with grooming and dressing activities and 50 points maximum for activities/participation ques.34 However.118 and the minimal measurement properties.115 indicated that the ASES.6 and 12. Studies of the SPADI have indicated adequate measurement Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Studies of the ASES indicate adequate level. 2014. SPADI.35.15. • Pain and difficulty with reaching activities: to the shoulder tions (10 questions). For personal use only.32. whereas the SST has only limited or no ACTIVITY LIMITATIONS evidence as to the error in the measure and clinically mean. 8. Most recently.1.5 points). for a maximum total of 35 points.76. however.org at on May 7. The total score The Constant score is the most widely used scale in Europe. or the recommended for use. a patient self-report section and a clinician.1115 points. has been reported to be between 6. Each domain score is equally weighted for the total score. with 0 indicating patients with shoulder disorders.76. and therefore this outcome measure is not measures.115. sport. Staples et al123 concluded that properties of the Constant score self-report section have been the SPADI had superior responsiveness when compared to investigated. SPADI. Clinicians should utilize easily reproducible activity er than measurement error at the 90% confidence level.53 the SPADI. 107 mains.15. DASH. Adhesive Capsulitis: Clinical Practice Guidelines CLINICAL GUIDELINES Examination OUTCOME MEASURES The DASH is a 30-question patient self-report question- There are several outcome measures designed to assess naire. It has 2 sections. DASH.118 The MDC or upper limb specific. der outcome tools for psychometric properties.118 societies involved with the treatment of shoulder pain are the Constant score. and SPADI have demonstrated acceptable psycho- metric properties.8. because there are only 4 items the DASH in patients with adhesive capsulitis. The shoulder outcome tools clinically important difference has been reported to be that are most widely used and embraced by professional 10.15. ranges from 0 to 100. 10. Therefore.4 sess the changes in the patient’s level of shoulder function points. level has been reported to be 18. with 100 properties.115 over the episode of care.

asked to actively abduct the shoulder to end range. ROM is measured by placing the axis of the goniometer on E ROM. 2014. until end range is reached. The movable supine with the arm comfortably by the side. Alternatively.108 Spe- Glenohumeral Internal Rotation in Abduction cifically. The stationary arm is aligned with the Glenohumeral External Rotation in Adduction midline of the trunk.99 flexed to 90°. To measure abduction ROM. and the elbow traclass correlation coefficients ranging from 0. Glenohumeral joint accessory vertical position. the patient can be asked to ducted. 0. The movable arm is aligned with the Glenohumeral External Rotation in Abduction midshaft of the humerus.org at on May 7. Active and Passive Shoulder ROM • I CF category: measurement of impairment of body func- tion: mobility of a single joint Shoulder Flexion • Description: the amount of active or passive ROM of the To measure flexion ROM. sured by placing the axis of the goniometer on the head of the humerus. the shoulder abducted to 90°.80 to 0. ROM in patients with adhesive capsulitis have yielded in- tioned in supine. The station.jospt.98 to 0. journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a15 43-05 Guidelines.99. The examiner passively eter. ROM is mea- shoulder to end range. Alternatively. the patient can be External rotation ROM may also be measured with the shoul. The stationary arm is aligned parallel with the midline of the sternum. passively abducts the shoulder until end range is reached Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. The movable arm is aligned with the ulnar motion may be assessed to determine translational glide loss. The examiner passively externally rotates the glenohumeral joint Downloaded from www. Motion can be performed supine or in the upright flexes the shoulder until end range is reached (with no com- position pensatory movements from the thorax and the lumbar spine). The examiner passively internally rotates the glenohumeral joint until end range is Clinicians should measure pain. ROM is measured by placing the axis of the goniometer on Measurement Methods the greater tuberosity. All rights reserved. ensuring that there is no scapular compensation. with the arm comfortably by the side. the patient is positioned in supine glenohumeral joint as measured with a standard goniom. the patient is positioned in supine with the upper actively flex the shoulder to end range.indd 15 4/17/2013 3:58:30 PM . ROM is measured by placing the Shoulder Abduction axis of the goniometer on the olecranon process. measures of passive shoulder external rotation Internal rotation ROM is measured with the patient posi. Alternatively. • Measurement properties: measurements of shoulder ROM made with a standard goniometer demonstrate intraclass correlation coefficients ranging from 0. active shoulder reached. If glenohumeral abduction is less than 90°. Placement of the • N ature of variable: continuous axis and arms of the goniometer is similar to what is used • Unit of measurement: degrees Journal of Orthopaedic & Sports Physical Therapy® with the adducted position.95. arm comfortably by the side and the elbow flexed to 90°. The movable arm is aligned with the To measure external rotation ROM with the shoulder ad. Adhesive Capsulitis: Clinical Practice Guidelines PHYSICAL IMPAIRMENT MEASURES styloid process.57 a 45° abduction angle can be used. the patient is positioned in ary arm is aligned with the vertical position. For personal use only. der abducted to 45° or to 90° in the frontal plane (if the pa- tient has the available abduction ROM). Alternatively. and passive shoulder ROM to assess the key impairments of body function and body structures in the olecranon process. (95% CI: 0. the patient can be asked to ac- tively internally rotate the shoulder to end range. lateral epicondyle.99). the patient can be asked to actively externally rotate the (shoulder must remain in the same plane). No other uses without permission. The examiner arm is aligned with the ulnar styloid process. The stationary arm is aligned with the patients with adhesive capsulitis.

and a total score of more than 30 on and a limitation of active and passive range of movement the SPADI. so Instead. in a more chronic stage.61 Carette et al23 performed a randomized controlled Ryans et al117 also investigated the effect of steroid I prospective study of 93 patients with adhesive cap- sulitis. with supervised therapy is more effective than 12 sessions of plicate pain and muscle guarding. All rights reserved. of conservative treatment. Moreover. The following studies im. The interventions were based on Downloaded from www. controlled study. blinded. and high levels of pa. and long-term efficacy of these interventions. 3 months. sions over a 4-week period. as well as isometric sive capsulitis. 2014. For personal use only. and supervised physical therapy. however. Therefore. This study tered to dampen the inflammatory response and reduce pain concluded that at 6 weeks.19. tive ROM exercises. the response to treatment exercises. tive treatment for adhesive capsulitis. or mobility or stretching exercises likely did not have adhe. This study compared 4 different interventions. tion and improved function over months as tissue remodels whether the patient was in a more acute “capsulitis” stage or from thickened fibrotic tissue to more normal collagen tis.23 except that in this study they did a16 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines.60 These are often the short-term outcomes ing ROM. No other uses without permission. as the initial barrier to joint motion because the was well controlled. pared to the uninvolved. Those in the acute group received sue. Group 4. patients who have. both CORTICOSTEROID INJECTIONS corticosteroid injection groups improved significantly more Although corticosteroid injections are not directly part of the than the 2 noncorticosteroid injection groups. performing both gle- nohumeral joint intra-articular and subacromial capsulitis and included in this study if they had symptoms injections. greater than 25% in abduction and external rotation com- Group 1 was treated with a fluoroscopy-guided glenohu. All groups performed a physi- treatment does not require the patient to achieve full ROM. the placebo group. glenohumeral joint intra-articular active and passive ROM were better in the corticosteroid corticosteroid injections for adhesive capsulitis are common. 6 months. therapy group demonstrated the largest change in the SPA- DI score. return of motion and reduced symptoms after receiving cor. At 6 weeks. Patients were classified as having adhesive cap- for more than 1 year. intra-articular injection alone or in patients with adhesive capsulitis.jospt. at times. shoulder pain with limitation of both sulitis and included in this study if they had a painful shoul- active and passive movements of the glenohumeral joint der in the fifth cervical nerve root dermatome distribution of more than 25% in at least 2 directions compared to the of more than 4 weeks and less than 6 months in duration. should consider receiving. the SPADI. however. Group 3 received a fluoroscopy- of adhesive capsulitis. and/ with therapeutic ultrasound. patients who present with shoulder pain and pain-relieving modalities (transcutaneous electrical nerve mobility deficits but have a relatively immediate significant stimulation and ice). In contrast. Journal of Orthopaedic & Sports Physical Therapy® physical therapist’s scope of practice. There were no differences ly seen by physical therapists. Patients meral joint intra-articular corticosteroid injection. active and active assisted ROM exercises. injection/physical therapy group. or the SPADI scores were similar among all 4 groups. the scores were not statistically different from the corticosteroid injection–only group. cal therapist–instructed home exercise program (HEP). placebo- 2 received a combination of the fluoroscopy-guided gleno. the corticosteroid injection/physical helps determine the diagnosis. and randomly assigned to 4 groups as per humeral joint intra-articular corticosteroid injection and the study by Carette et al. Corticosteroids are adminis. Patients were classified as having adhesive I injections and physiotherapy. as opposed to fibrosis or supervised physical therapy or a HEP. and the SF-36 as outcome measures. Successful had only a saline injection.indd 16 4/17/2013 3:58:31 PM . contralateral shoulder. Adhesive Capsulitis: Clinical Practice Guidelines CLINICAL GUIDELINES Interventions Multiple interventions have been described for the treatment supervised physical therapy. low-grade joint mobilizations. A successful long-term outcome Supervised physical therapy consisted of 12 one-hour ses- could be defined as a continual improvement in shoulder mo. Patients reduction of pain. contralateral shoulder. a successful outcome may be defined as a significant those in group 4 can be considered the HEP group. and there is emerging evidence from guided glenohumeral joint intra-articular saline injection high-quality randomized clinical trials regarding both short. in outcomes among the 4 groups at 12 months. the placebo group (intra-articular saline results of all studies demonstrate significant improvements injection and a HEP) is considered by others to be an effec- in motion immediately following steroid injections. were assessed at 6 weeks. Group (n = 80) were assessed in a randomized. soft tissue or joint mobilization. Those in the chronic group were treated ticosteroid injections. At 6 months. high-grade joint mobilizations. and ac- Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Although this study adhesions.org at on May 7. and 1 year us- tient satisfaction. improved function.

and pain using a VAS were used to as. The mean duration of physical therapy was 2 weeks. and a reduction in exter- II ized. The authors concluded that steroid injections cular facilitation. joint mobilization. adhesive capsulitis and included in the study if they had Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®.” compared to only 46% of those treated analog scale (VAS). Physical therapy consisted of twelve than other interventions. 26 and 52 weeks. restriction of injection group. used to reduce pain. All rights reserved. the 2 groups for any of the outcome measures. The exercises. external rotation was more limited than abduction information that steroid injections were more efficacious and internal rotation. at the therapist’s discretion. and electrical stimulation could also be physiotherapy program included proprioceptive neuromus. to a lesser extent. Thirty-two patients study concluded that there is little long-term advantage of were given the low-dose injection. Treatment success was based on the sess outcomes. Both sleep syndrome). sleep disturbance at night due to pain. it demonstrated that higher-dose journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a17 43-05 Guidelines. and 6 weeks. The inclusion criterion for this study was painful. with no concurrent intervention used. No significant differences more reduction of external rotation. reaching statistical significance for improved passive ROM of the glenohumeral joint. For personal use only. and both Bulgen et al19 compared 4 intervention groups: groups performed a HEP. using a VAS. Physical therapy consisted relieving shoulder disability and physiotherapy for improving of hot packs. and no difference was noted among Arslan and Çeliker4 randomly allocated 20 pa- groups. Statistically significant differences be- group. and exercise. a VAS for pain. and improvement study if they had a spontaneous onset of shoulder pain or the continued until 6 months. Heat. so the placebo group can be considered the HEP much improvement. 3.indd 17 4/17/2013 3:58:32 PM . a 16-item functional disability questionnaire. All groups performed a standardized HEP of patient’s self-rating of having made complete recovery or stretching. steroid injections im. Journal of Orthopaedic & Sports Physical Therapy® patients. Measurements were taken at 1. with physical therapy. intervals. Criteria for inclusion were pain in the shoulder for at least 1 month. tients completed the study at 16 weeks. and wall climb. van der Windt et al129 compared intra-articular and functional shoulder and arm ability measured using a II injections (average of 2. de Jong et al38 performed a prospective. sive glenohumeral stretching exercises. At proved in the SDQ compared to the other 2 groups. in. and triamcinolone acetonide (corticosteroid) intra-articular in- shoulder ROM were used for outcome measures. occurring most tion or a combination of physical therapy and a nonsteroi- often in the placebo/HEP group. double-blind study in which they investigated the use of low-dose (10 mg) and high-dose (40 mg) nal rotation ROM of at least 50%. alone were as effective as physical therapy for improving formed at home) in a prospective randomized study of 41 ROM and reducing pain. Three injections were given at weekly prove ROM and. but not pain.2 per patient) to physical therapy in a prospective randomized controlled 4-point ordinal scale. Patients were classified with the use of intra-articular and subacromial corticosteroid in.jospt. pas- external rotation ROM. A limitation of this study is that only 71% of the pa. In this study pop. and disruption of sleep in outcomes were seen among the groups at 6 months. interferential electrical stim. Outcome assessment ulation. mobilization. in the higher-dose group. The authors recommended dal anti-inflammatory drug. ultrasound (3. described as a 45° or motion. and only 8 sessions 30-minute sessions involving passive joint mobilization and of physiotherapy over a 4-week period were delivered. Significant differences in pain were found at all fol- trial on 109 patients with a stiff. Adhesive Capsulitis: Clinical Practice Guidelines not use fluoroscopy-guided injections. ice/proprioceptive neuromus- revealed similar improvements in both groups at 2 weeks and 12 weeks. tween groups were found in nearly all outcome measures. and ROM. passive ROM. global self-rated disability using a visual treatment “successes. Treatment cular facilitation. jections to provide short-term improvements (6 weeks) for less than 50% of normal motion. ice. painful shoulder (capsular low-up intervals. Outcomes included a pain VAS. Pain. Pain was jections given to patients with adhesive capsulitis. and no treatment (pendulum exercise per. No other uses without permission. high-dose injection. random- ability to lie on the affected shoulder. At 7 weeks. While this study did not provide ulation. the 2 injection groups significantly im. 2014. All groups significantly improved by 16 weeks. favoring the high-dose group. The while lying on the affected shoulder. The Shoulder Disability Questionnaire included the SDQ. whereas 25 received the one treatment over the other. active 77% of the patients treated with injections were considered and passive ROM. disturbances of sleep. at 4 weeks. there were no differences noted between patients treated in supervised physiotherapy gained signifi.5 W/cm2 for 5 minutes). however. (SDQ).org at on May 7. cantly more external rotation motion. pain in the first 4 weeks. restriction in all active and passive shoulder movements. was varied based on symptom severity. Patients significantly reduced and ROM was significantly improved by were classified with adhesive capsulitis and included in the the fourth week of treatment for all groups. Improvement was greatest in the shoulder pain was caused by a minor trauma. The most common intra-articular glenohumeral joint steroid injec- reason of attrition was failure to improve. ROM and pain outcome measures II paired intra-articular and subacromial injections. II tients with adhesive capsulitis to receive either an Downloaded from www. disturbance and functional ability were significantly better restricted glenohumeral passive mobility. however. At 6 weeks.

or osteoarthritis based on diagnostic ultra- sound and radiography were excluded from the study. At IV roscopic-guided intra-articular corticosteroid injec- tions. exter. the authors found no difference be. Inclusion criteria were the presence of shoulder pain ondary frozen shoulder. the diagnostic difficulty of distinguishing primary from sec- sulitis. The criteria for groups had marked improvement in all parameters. external rotation less than 20°. The results nal rotation. with at least 25% limitation of both active and passive move- ments of the glenohumeral joint in at least 2 directions. both frozen shoulder. at pretreatment and at 4. 6. No other uses without permission. Physical therapy was started after 4 weeks and consisted of joint mobilization All injections were performed under diagnostic ultrasound– twice a week and instruction in a daily stretching exercise guided conditions. Los Angeles end-result scores were statistically findings were consistent with stage 2 Reeves classification better in the corticosteroid group. none of the dif. 24. SPADI total a mean age of 49 years and stage 2 adhesive capsulitis were score. on relieving symptoms related to adhesive capsulitis. 25° study if they had limitations of both active and passive mo. This study process of the third lumbar vertebra). 2014. subacromial injections may be added as a potential intervention strategy. and SPADI pain score and medians of University of included in this study. and ROM were used as outcome measures. Lorbach et al70 reported on the effectiveness of fluo- tween 6 weeks and 6 months of symptom duration. 16 female) with Journal of Orthopaedic & Sports Physical Therapy® the second week. and 12 weeks after I shoulder to a group that received manipulation under anesthesia or a group that received an intra- the injection. A pain VAS. gies (diabetes types 1 and 2) and patients who had received No differences between groups were noted at 6 and 12 weeks. and sleeper stretch exercises. Adhesive Capsulitis: Clinical Practice Guidelines corticosteroids (40 mg compared to 10 mg) had greater effect secondary frozen shoulder due to rotator cuff tendinopathy. ROM mea- not performed until shoulder pain subsided. for abduction. that because subacromial tissue may be involved in primary II tween intra-articular corticosteroid injections and intra-articular serum physiologic injections. Interestingly. I were randomly assigned to receive glenohumeral joint versus subacromial corticosteroid injections. For personal use only. steroid injection with distention over manipulation under primary frozen shoulder may have had secondary frozen anesthesia. the pain VAS at 3 weeks demonstrating a statistically signifi- Exclusion criteria included additional or alternative patholo. The most significant gains were noted in the first 4 tolerance. Data Jacobs et al56 randomized 53 patients with frozen were collected at preinjection and at 3. still only averaged 73 of 100 possible points. be. Outcome mea- dal anti-inflammatory medication and a HEP consisting of sures were ROM.to 10-second hold time to 1 year. with only patients to be included in this study were not clearly defined. 12. sures at 4 weeks and further progress being made through ercise for 10 repetitions with a 5. Patients were included if their clinical California. Both groups were treated with nonsteroi. for patients with adhesive cap. Strengthening exercises were weeks following the first injection. articular injections. or internal year. Patients were sures compared to the uninvolved side at 1 year still demon- diagnosed with primary frozen shoulder and included in this strated significant relative restrictions of 24° for flexion. a pain VAS. The authors. a steroid injection into the affected shoulder before referral. 8. calcific tendinitis. The study highlighted the idea Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. At short-term intervals as well as concluded that a subacromial corticosteroid injection was as at the 2-year follow-up. This study also highlighted followed by a 12-week HEP. The ASES score. changes in abduction ROM. many patients thought to have Downloaded from www. program in pain-free ranges of movement. because the clinical outcome was the same but shoulder stemming from rotator cuff tendinopathy. Twenty-five patients (9 male. thors also recognized that they did not use any control group that only performed exercise.93 with a 4-week interval between injections. The au- with less risk. However.indd 18 4/17/2013 3:58:32 PM . effective as an intra-articular corticosteroid injection. The Constant score and ROM measures were not statisti- The manipulation consisted of forced motion using a short cally different at any time frame postinjection. All rights reserved. and the could not rule out all forms of rotator cuff tendinopathy using SF-36. Therefore. or signs of glenohumeral joint osteoar- thritis were excluded from the study. 3 to 5 times daily. The authors determined that both articular steroid injection with distention. Internal rotation tion in at least 2 directions (abduction and forward flexion ROM was not found to be different from side to side at 1 less than 100°.org at on May 7. the Constant score. and the SF-36 administered gentle active assisted and passive flexion.jospt. previous intra- ferences between groups remained significant at 12 weeks.70 Patients with diabetes mellitus. They tween the 2 groups in the Constant score. and 15° for external rotation. The authors lever into all end ranges. adduction. therefore. and no treatment other than analgesics in the previous 6 months. The demonstrated significant improvement in all outcome mea- instructions for the HEP consisted of performing each ex. cant difference favoring the intra-articular injection group. although dramatically improved at 1 rotation less than reaching behind the back to the spinous year. criteria. Patients demonstrating demonstrated the short-term benefit of intra-articular ste- a18 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines. Bal and colleagues6 examined the difference be. ASES score. Treatment consisted of Seventy-one patients with primary frozen shoulder 3 fluoroscopically guided intra-articular cortisone injections. recommended intra-articular ultrasonography. abduction. and 52 weeks.

No other uses without permission. the impact of a singular modality A with shoulder mobility and stretching exercises are more effective in providing short-term (4-6 weeks) on the natural course of adhesive capsulitis is difficult to de- termine. The criteria to be included in this study were shoul- of patients with adhesive capsulitis. and for flexion of the glenohumeral joint in all directions for a period of 3 and abduction immediately posttreatment. improvements of ROM were not correlated with pain. as therapeutic modalities are typically applied as pain relief and improved function compared to shoulder mo. Patients after entering the study. pain with motion. At I review assessing the effectiveness of corticosteroid injections compared to physiotherapy interven- 24-month follow-up. and active stretching techniques within the up. injections when compared to physiotherapy interventions. yet their recovery follows a fairly predictable course. (2) promotes activity modification to encourage in the treatment of adhesive capsulitis at short term and to a functional. exercises. pain-free ROM. stretching to the patient’s current level of irritability.indd 19 4/17/2013 3:58:33 PM . pain with motion with a minimum VAS score of experience exquisite pain in the early stages of adhesive cap. reaching statistical were classified as having adhesive capsulitis and included significance for internal and external rotation immediately in this study if they had more than 50% motion restriction posttreatment and at the 3-month follow-up. the end of the 10th treatment session and again 3 months I pervised neglect” compared to aggressive therapy in 77 patients with adhesive capsulitis. 2014. 89% of the patients in the “supervised neglect” group achieved a Constant score of 80 or greater tions for adhesive capsulitis. adhesive capsulitis is perplexing to patients. dis- ing “supervised neglect” was provided with “an explanation ability. Both groups tivity modification. for the treatment of adhesive capsulitis in 49 pa- pist interaction and critical to the rehabilitative management tients. followed by Patients need to understand that exercises should be per. Ten ultrasound treatments (3-MHz frequency Describing the pathology (synovitis/angiogenesis progressing for 10 minutes at 1. The aggressive therapy group was treated when compared to the uninvolved extremity. Dogru et al40 conducted a randomized controlled II Journal of Orthopaedic & Sports Physical Therapy® PATIENT EDUCATION trial analyzing the effects of therapeutic ultrasound Patient education is central to each patient-physical thera. via an electrical hot pack at 60°C for 20 minutes. However. approximately 25% still had significant ROM restrictions pain-free ROM. However. Six studies were determined out of 100. For personal use only. SF-36 scores. and internal rotation were taken at Diercks and Stevens39 investigated the use of “su. Small effects were also present in the time range from 12 to Clinicians should utilize patient education that 52 weeks. Patients generally movement. These patients were Blanchard et al13 performed a systematic literature also encouraged to perform a HEP of maximal reaching. journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a19 43-05 Guidelines. pendulum and active ROM exercises. is important to prevent self-imposed immobilization. and normal findings on radiographs of the glenohu- sulitis. or general health status. external rotation. adjunctive treatments to manual therapy and/or therapeutic bility and stretching exercises alone. in supervised therapy with exercise and manual techniques up to and beyond their pain threshold. indicating that the “supervised neglect” treatment ap- weeks there was a medium effect in favor of corticosteroid proach was superior to more aggressive therapy. Heating or electrical modalities theoretically can have posi- tive benefit on pain in the treatment of patients with adhe- Intra-articular corticosteroid injections combined sive capsulitis.jospt. meral joint. while emphasizing functional pain-free of patients also received superficial thermotherapy provided ROM. Encouraging ac. All rights reserved. The insidious nature of der pain for a minimum of 3 months with no major trauma. ROM improvements were greater in the ultrasound versus the sham group. The review also showed that phys. versus 64% of those in the aggressively mobilized eligible for inclusion. and (3) matches the intensity of Downloaded from www. of the natural course of the disease.org at on May 7. 40 mm. who often have greater than 25% loss of shoulder motion in all planes of concerns about serious medical conditions. lum exercises.5 W/cm2) were performed to the affected to fibrosis) can allay fears and prepare them for the staged shoulder over a 2-week period. these months or more. Their conclusion was that corticosteroid injec- tions were more beneficial than physiotherapy interventions B (1) describes the natural course of the disease. The control group was treated progression of the condition and recovery. lesser extent at long term. The authors reported that at 6 to 7 group. The group of patients defined as receiv. iotherapy interventions led to a better outcome than when patients did not receive any intervention (control group) and therefore offer a positive alternative for patients who MODALITIES Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. with sham ultrasound using an inactive unit. scores. and ROM measurements for flex- ion.” instruction in pendu- Although 90% of the patients were satisfied at 1-year follow. declined injection. SPADI formed without significant pain. Adhesive Capsulitis: Clinical Practice Guidelines roid injections in patients with primary adhesive capsulitis.

provided. it is difficult to conclude wheth. Treatment was In a nonrandomized prospective study of 50 pa- continued until patients had achieved at least 80% of the normal passive ROM of the shoulder. ing versus stretching alone. For personal use only. Treatments were performed 2 to 3 times per posterior electrodes.indd 20 4/17/2013 3:58:34 PM . Significant improvement in overall ROM response. Adhesive Capsulitis: Clinical Practice Guidelines Mao et al74 utilized arthrography to quantify chang. all groups had week for 4 to 6 weeks. night pain. improved significantly on the Constant-Murley assessment Manual treatments were performed for 1 hour 3 times per score and the pain VAS. both treatment groups Journal of Orthopaedic & Sports Physical Therapy® shoulder motion. most improvements were noted in the first 2 weeks of treatment. and 90° of external rotation.2 W/cm2 for 8 minutes). diathermy for 20 minutes. After the intervention. 50° of external rotation. and stretching alone. defined as having sound (1 MHz. com. Leung and Cheing67 recently sought to answer IV es in glenohumeral joint volume in 12 patients with adhesive capsulitis treated with deep heating mo- II whether superficial and deep heating modalities were useful adjunctive treatments to a self-stretch- dalities as adjunctive treatments to passive mobilization and ing program. capsular volume was associated with an increase in external Patients treated with shortwave diathermy demonstrated sig- rotation ROM. techniques such as joint mobilizations and transverse friction interferential electrotherapy plus exercise. These differences were maintained at the 6-month pack for 20 minutes followed by 20 minutes of shortwave follow-up. The exercise groups received 10 treat- trauma. the stiffness stage of adhesive capsulitis. Both groups performed active stretching and pendulum exercises following their sessions and a HEP.12-MHz oscillation frequen. Patients were included in this study if they had tis and included in this study if they had shoulder pain for a pain in 1 shoulder. 70° of control group was included.” including superficial simple home stretching in the treatment of patients with ad. Because the majority of patients had a rapid sive mobilization. history of pain and stiffness in the shoulder for more than Patients were treated for 20 minutes 3 times per week for 4 1 month. er treatment groups. it also appears that the adhesive capsulitis diagno.12-MHz wave through anterior and external rotation. The authors randomly assigned 30 patients in a home program. The hot-pack treatment utilized an electrical hot pack motion. and a combination of active and pas- hesive capsulitis. whereas the control group did not week. Patients were classified as having adhesive capsuli. or no treatment massage. comparing the use of moist hot pack and continuous shortwave diathermy to Cyriax-inspired manual II 70 patients with frozen shoulder were randomly as- signed to receive electroacupuncture plus exercise. nerve stimulation (50-150 Hz for 10 minutes) together with tation. for 4 weeks. randomized trial of 42 patients with adhesive Cheing and colleagues26 designed a study in which capsulitis. pain with ment sessions. idiopathic pain and loss of motion in the shoulder of at least whereas the other patients received continuous shortwave 8 weeks’ duration. 120° of abduction. 0. loss of active and passive shoulder ROM. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Patients in the modalities group received moist hot change. 70° of internal ro. The authors found that an increase in improvements in the ASES score and ROM measurements. was found in the group treated with transcutaneous electri- sis was loosely applied to patients presenting with shoulder cal nerve stimulation. this may have been due to pain and that true adhesive capsulitis was likely not present the prolonged end-range stretching that was concurrently in many of the patients included in the study. however. as no analysis was performed. 2 intervention groups. Guler-Uysal and Kozanoglu46 conducted a prospec- II tive. Shortwave diathermy was provided at a comfortable ion. tis and included in this study if they had pain on resisted pared to only 65% of those who received the heating modali. and shoulder ROM limited to less than 140° of flex. could not be determined because no control group was used. continuous. Rizk et al109 inves- tigated the application of transcutaneous electrical fined as 180° of flexion and abduction. internal rotation. All rights reserved. but because no tion (with external rotation). shoulder pain elicited at end range of all planes of weeks. exclusive restriction of glenohumeral joint motion ties. and 140° of flexion. Study inclusion criteria were a shortwave diathermy and stretching. Ninety-five percent of prolonged end-range stretching performed with overhead patients who received manual techniques achieved the 80% pulleys. and restricted active and pas- minimum of 2 months with no major precipitating shoulder sive shoulder ROM. which the authors de- III tients with adhesive capsulitis. a20 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines. cy). 70° of internal rotation. Half of the 12 participants received ultra. The authors concluded that manual therapy treatments with maximum passive ROM not exceeding 110° of abduc- were more efficacious than passive heating. No other uses without permission. The comparison group er superficial and deep heating was any more effective than received “standard physical therapy. at 63°C. and a minimum VAS pain score of 30 mm.jospt. In addition.8-1.org at on May 7. Patients were classified as having adhesive capsuli- milestone by the end of the second week of treatment. 2014. heating modalities. to 3 groups: hot pack and self-stretching. and there were no significant differences Significant differences in outcome between the 2 forms of between groups treated with superficial heating and stretch- deep heating are also unknown. with no significant differences noted between the diathermy (220 V/50 Hz at 27. and 50° of heating intensity via a 27. At the 4-week follow-up. The actual efficacy of the heating modalities nificantly greater improvement in ROM compared to the oth- Downloaded from www. motions.

the mobilization evidence that it may be beneficial. tained a severe trauma. or had osteoarthritis. injection). 8-week period. and although there is exercises performed at home).130.jospt. or active ROM between the 2 groups. joint mobilization. ultra. Limitations of this study were lim- Patients were included in this study if they had unilateral ited measures of pain and ROM and only a 4-week follow-up. self-perceived the patients received other therapies (medication. No other uses without permission. treatment groups with physical impairments that presum- ably best respond to joint mobilization131 and (2) where the Nicholson91 compared a group of patients with ad- mobilization force is best matched to the tissue irritability of the patient60 may provide a clear indication of whether II hesive capsulitis who received joint mobilization and active exercise (n = 10) to a group receiving Downloaded from www. they found significantly improved ROM and reduced pain in Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. adhesive capsulitis. global improvement.org at on May 7. less than 140° a pain VAS. Inferior. ROM. The criteria for patients to be included capsulitis. or electrical stimulation combined with mo- bility and stretching exercises to reduce pain and sive shoulder motions. and advice (n = 39) to a formed. there were no statistically ventions was small. and 12 months using for patients to be included in this study were unilateral shoul- the Shoulder Rating Questionnaire. Patients treated with joint mobiliza- improve shoulder ROM in patients with adhesive capsulitis. and no modalities or HEP were per- II with shoulder pain and stiffness who received joint mobilization. but there was no significant difference in long-term outcomes between these patients and those who were only treated with Vermeulen et al130 presented a case series of 7 pa- joint mobilization for the 3-month treatment period. Following 4 weeks of treatment. After 3 months. SDQ. and der pain reproduced during shoulder motion. This study demonstrates that grade I and II mobilization (not ten- IV tients with a diagnosis of adhesive capsulitis treated solely with intense end-range mobilization tech- sioning the tissue to end range) can be effective in not only niques (no exercise or modalities) over a 3-month duration. with the only difference between groups being a slightly greater improvement (7°) in passive abduction for mobilization techniques without the inclusion of exercises. but only a minority of comparisons reached statistical ceived a maximum of ten 30-minute therapy sessions over an significance. in this study were shoulder pain and limited passive motion of the glenohumeral joint.57.indd 21 4/17/2013 3:58:34 PM . At 1 and 6 months. a restriction of more Bulgen et al19 compared 4 intervention groups: than 50% in passive shoulder abduction. joint mobilization is beneficial for patients with adhesive just exercise (n = 10). and the overall difference between the 2 inter. ice/proprioceptive neuromus- tal plane. sus- in a prospective randomized study of 41 patients. Patients were teria for patients to be included were pain in the shoulder treated 2 to 3 times a week. Vermeulen et al131 performed a randomized pro. and a reduction in external rotation motion of at least 50%. inability to (measured by arthrography) were used to determine out- journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a21 43-05 Guidelines. there is little evidence to group significantly improved relative to initial ROM and pain support superior efficacy over other interventions. night pain while sleeping. The high-grade mobilization group did testing of the joints in the shoulder region. SF-36. but slightly less than patients receiving intra-articular and subacromial injections. and posterior glide techniques of active shoulder flexion and abduction ROM. There was no control group. approximately 25% of significant differences in pain and disability. the mobilization group. and both ROM and joint volume for at least 1 month. 6. anterior. and maximal glenohumeral joint capacity of 15 cc. 2014.19. but no difference was noted when compared to the Future research designs where patients are classified into (1) other treatment groups. exercise. The patients were treated 2 times a week for 30 min.131 measures. a greater than were used in addition to distraction techniques. restriction in all active and pas- C sound. Adhesive Capsulitis: Clinical Practice Guidelines Clinicians may utilize shortwave diathermy. The group treated with joint mobi- JOINT MOBILIZATION lization did no better than the other 2 groups (propriocep- Several studies have examined the effect of joint mobilization tive neuromuscular facilitation/ice/HEP and just pendulum in patients with adhesive capsulitis. II spective study (n = 100) comparing high-grade (grades III and IV) to low-grade (grades I and II) both groups. Patients were cular facilitation. and pain and/or stiffness during accessory movement the first 3 months.91. flexion in the sagit- II paired intra-articular and subacromial injections. lateral rotation compared to the opposite side. group receiving just exercise and advice (n = 39). The diagnostic criteria for adhesive capsulitis were a pain- ful stiff shoulder for at least 3 months. and no treatment (pendulum exercises) excluded from the study if they had diabetes mellitus. improving pain but also increasing ROM and function. The cri. lie on the affected shoulder. Participants re- better. For personal use only. All rights reserved. tion and a HEP significantly improved in the first 4 weeks. The authors 10-cm hand-behind-back deficit compared to the unaffected found significant improvement in both groups occurring in side. At 6 months. The criteria Journal of Orthopaedic & Sports Physical Therapy® utes for 12 weeks and assessed at 3. defined as greater than 50% loss of pas- sive movement of the shoulder joint in 1 or more directions Chen and colleagues27 compared a group of patients and duration of complaints for more than 3 months.

A compliance with the HEP had greater influence on motion 2-person manipulative technique was used so that 1 clini- return and time to motion plateau than frequency of joint cian could stabilize the scapula while the other performed the mobilization. as opposed to assessing changes in Yang and colleagues138 performed a multiple-treat.7 years were No oscillatory motions were performed. Mobilization Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Study inclusion criteria were painful both anterior and posterior glides were chosen.indd 22 4/17/2013 3:58:35 PM . Patients were classified as different sequences for a total of 12 weeks. gender. other shoulder motions and/or an accepted outcome tool. tion and self-exercise compliance. 58 female) with an average age of 63. effect of 2 directions of mobilization on external rotation including but not limited to exercises such as wall climbs. All rights reserved. They reported significant improvement in active and teria limitations for inclusion in this study were not defined. handedness. The results showed no difference in Roubal et al114 described an alternative treatment improved motion based on gender. and the low-frequency group was treated less than once a week. For treatment. and mobili- tients may have gained motion in other planes in the different treatment groups that went undetected. Adhesive Capsulitis: Clinical Practice Guidelines comes. ment function questionnaire. No other uses without permission. The pain VAS. They tients with adhesive capsulitis. translational manipulation. however. Pa- cal history and no clinical or radiological findings identifying tients were treated for a total of 6 sessions over 2 to 3 weeks. Another limitation is the exclusive use of active abduction as the outcome measure. Patients were initially treated with ultrasound to the II management for limited glenohumeral motion fo- cusing on frequency of sessions for joint mobiliza- anterior capsule or posterior capsule based on treatment with anterior or posterior mobilization. A versus the involved nondominant extremity. (52 male.130 The with anterior glide mobilization. The high-frequency group was treated 2 times a week. an inferior glide a22 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines. 2014. for a total of and limited shoulder motion with an unremarkable medi. A limitation of this study is that the motion cri. passive ROM. Each treatment was given for a 3-week period in female) with adhesive capsulitis. a 5-item self-assess- with movement in increasing motion and function. Pa- IV ment trial using various combinations of end-range mobilization. respectively. Measured outcomes were active abduction ROM and C primarily directed to the glenohumeral joint to re- duce pain and increase motion and function in pa- the time required (months) to reach ROM plateaus. and self-exercise compli. better improve- ment in motion was seen in the involved dominant extremity IV method to standard shoulder manipulation for patients with unresponsive adhesive capsulitis. significant osteoporosis. This study indicated that greater history to undergo an interscalene brachial plexus block. No HEP was performed. They found im.org at on May 7. but did not compare mobilization to other forms of Patients were randomly assigned to 1 of 3 frequency-of-treat. treatment or assess the effect on other motions. Two techniques for enrolled in the study. Patients were classified as having adhesive capsulitis and Johnson et al57 investigated the effectiveness of an- included in this study if they had a painful shoulder for at least 3 months with ROM losses of at least 25% in at least 2 II terior versus posterior glide mobilization on exter- nal rotation ROM in 20 patients (4 male and 16 directions. pain. the an interscalene brachial plexus block administered by an an- improved motion was significantly better and time to pla. shoulder pathology. esthesiologist. One hundred ten patients was applied to end range with a sustained stretch of 1 minute. ment groups. of cancer. or inappropriate cardiovascular and smaller gains in ROM. and external rotation ROM in Downloaded from www. This study compared the Journal of Orthopaedic & Sports Physical Therapy® HEP consisted of pendulum and passive stretching exercises. For personal use only. the highest degree of abduction were used for outcome mea- Tanaka et al124 attempted to identify the preferred sures. Patients treated with posterior glide dardized intervention including shoulder joint mobilization mobilization demonstrated significantly greater improve- and instruction in a HEP. Mobilization techniques were ment in external rotation ROM compared to those treated high-intensity mobilizations performed at end range. the moderate-frequency group was treated once a Clinicians may utilize joint mobilization procedures week. Each patient was treated with a stan.jospt. and joint volume following treatment. duration of symptoms before rehabilitation intervention. midrange mobilization. motion. However. TRANSLATIONAL MANIPULATION ance in a home setting. MRI or clinically dem- A relationship was seen between longer symptom duration onstrated rotator cuff tear. also assessed the effect of age. They concluded that end-range mobilization and external rotation increased as the shoulder was moved to- midrange mobilization were more effective than mobilization ward greater abduction. having adhesive capsulitis and included in this study if they proved active mobility and self-reported levels of function at had external rotation motion restriction and if restriction in 12 weeks. frequency of sessions for joint mobilization. 15 minutes of sustained stretch at each treatment session. zation with movement in 28 patients with adhesive capsuli- tis. The frequency single session of translational manipulations was performed of use of joint mobilization showed no relationship with on 8 patients with recalcitrant adhesive capsulitis following improved motion or time to motion plateau. Patients were excluded if they had a history teau shorter in the group that performed a HEP every day.

Re- tion performed in this manner.3 grade III mobilizations. A VAS for pain and a functional outcome measure after 3 trials. They were subse. outcome tool was used in this study. Each II clinical trial (n = 125) comparing a HEP to a com- bination of manipulation under anesthesia and a began a postmanipulation ROM and physical therapy pro. Both pain and function forward flexion for 5 minutes every hour while the intersca. a Medrol (methylprednisolone 4 mg) 1-week dose pack (Pfizer Inc. leading to regaining elevation motion.jospt. No shoulder-specific not responding to conservative interventions. eficial for patients with adhesive capsulitis. painful active and to guide the optimal frequency. Following the was maintained or improved at both physical therapy dis- manipulation. Significant increased increase in passive ROM in all directions posttreatment.117 There is only 1 study45 for which the authors fully described the exercises tion of symptoms was 7. sults are inconsistent across multiple studies. internal rotation) while intensity that matches the given level of tissue irritability is measured under anesthesia. All patients were successfully manipulated. ROM. The authors concluded that translational gliding could repetitions of 20 seconds’ duration in all directions every 1 to be performed in an outpatient setting and without the poten- Downloaded from www. Therapy consisted of ice. have STRETCHING EXERCISES a close relationship with an anesthesiologist. The 6 patients who responded to the manipulation had sustained increased C under anesthesia directed to the glenohumeral joint in patients with adhesive capsulitis who are function and active and passive motion. all patients were instructed to perform passive charge and long-term follow-up. except the 4 with diabetes mellitus. Exclusion criteria included a history of cancer. The criteria for patients to be included in this study gram identical to that described in the study by Roubal et were gradually increasing shoulder pain and shoulder mo- al. 2014. NY) was initiated for 4 of the patients. manipulation. times a week for 1 to 5 weeks. but not necessarily more than other interventions. at discharge from physical therapy (5. and at a long-term follow-up visit (14. The posterior transla- volt galvanic electrical stimulation. and passive mo. Adhesive Capsulitis: Clinical Practice Guidelines manipulation was followed by a posterior glide manipulation.19. all manipulations were preceded by Kaltenborn weeks). joint mobi. matched to the tissue irritability of the patient60 may provide tor cuff tear. which patients demonstrated no change in motion. in all directions. (Wolfgang Scale) were assessed at initial evaluation.114 ROM was assessed premanipulation. HEP. comes (at 3-6 months) in patients treated with a therapist- IV nipulative procedure as described by Roubal et al114 in 31 patients (32 shoulders). external rotation. or passive motion. No evidence exists clusion criteria were decreased function. consisting of ROM stretching for 5 terval. tion was felt to restore both external and internal rotation lization. MRI or clinically demonstrated rota. For personal use only. abduction. number of repetitions. stretching ion. with the other studies simply describing the pro- of previous physical therapy treatment sessions was 7. No other uses without permission. The authors felt that the inferior translation techniques quently treated in physical therapy daily for 1 week and 3 stretched or disrupted the adhesions within the inferior fold. bility of no more than 140° of elevation and 30° of external journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a23 43-05 Guidelines. or inappropri. future research de- greater than 2 months’ duration of symptoms and no medi. A HEP motion by stretching the posterior capsule and rotator cuff in- was used in the first week. then a Maitland grade V manipulation was per. upper extremity neurologic deficits. ate cardiovascular history to undergo an interscalene brachial plexus block.4 months  7. significantly improved at discharge and at long-term follow- lene brachial plexus block was in effect. and stretching and strengthening exercises. Therefore. 2 hours. and at the long-term follow-up. The average dura- directed HEP or other interventions. Two motion was reported immediately postmanipulation. duration of stretching exercises. recent a clearer indication of whether stretching exercises are ben- fracture.7. immediately post. Inclusion criteria also included indicated. In. ultrasound. New Clinicians may utilize translational manipulation Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. On the day of the manipulation. All Kivimäki et al61 performed a randomized controlled patients. up. but the therapist must carefully screen appropriate patients. As with joint mobilization. This study provides an alternative option to commonly performed manipulation. and recognize Stretching exercises appear to influence pain and improve that not all patients will respond to translational manipula. rheumatic disease.org at on May 7. and if no increased motion was noted months). York. All rights reserved. Stretching beyond painful bility deficits with total ROM loss greater than 40% (flex.61. to stretching exercises131 and (2) the forces applied are best significant osteoporosis. limits may result in poorer outcomes.indd 23 4/17/2013 3:58:36 PM . signs where (1) patients are classified into treatment groups cal contraindications to undergo an interscalene brachial with physical impairments that presumably best respond plexus block.3  3. at dis- formed. Six of 8 patients experienced a significant immediate charge. pain-free resisted testing.2 Initially. started the use of oral steroid medication the day before manipulation. The HEP continued to emphasize stretching in the tial complications experienced with standard rotatory ma- second week and included strengthening with elastic bands nipulative techniques typically performed under anesthesia. demonstrating Journal of Orthopaedic & Sports Physical Therapy® that stretching results in minimal or no difference in out- Placzek et al101 reported on using the identical ma. prolonged steroid use. gram as active and/or passive exercises. high.23.8 months and the average number performed.

tion relative to their uninvolved side. At 6 weeks and at 3 months. was determined the number of visits. manual stretching. The mean duration of follow-up was 22 strengthening improved because the scapulohumeral rhythm months (12-41 months). Adhesive Capsulitis: Clinical Practice Guidelines rotation. Diercks and Stevens39 prospectively followed 77 pa. glenohumeral joint mobilization. 89% of the pa. they continued to demonstrate restricted mo- group demonstrated statistically greater increase in shoul. compared to only 63% of those in demonstrated small rotator cuff tear on MRI. All patients performed a HEP. randomly assigned to 2 groups. Both groups had signifi. “supervised neglect. measures were pain. All patients performed a HEP of passive stretching visually assessed. and ROM were assessed at 6 and 12 weeks. tive exercises within the painless range of movement. and ice. the The authors suggested that the group treated with scapular SST. in contrast to none of those in the intense physical nerve stimulation. However. treatment tended to have the worst outcomes. however. (n = 65) over a 6-week course of treatment. pist-instructed HEP for the treatment of adhesive capsulitis patients to be included in this study were not specified. There was no perceptions of pain and function of their shoulder prior to difference in outcomes between groups at any follow-up in. They compared to manipulation under anesthesia combined with found that both exercise groups (with and without cortico- a HEP. 16°). terval for pain or working ability.org at on May 7. Outcome with the group treated with scapular strengthening show- ing statistically greater active elevation ROM at 12 weeks. Patients with the worst der flexion ROM (mean. males) with an average age of 52. Griggs et al45 performed a prospective functional Both groups significantly improved in all outcome measures. and flexion compared to the other side. For personal use only. 8°. and a HEP. and internal rotation. and 5 of these 7 underwent manipulation and/ and shoulder ROM were assessed at 6 weeks and at 3. The frequency and length of care intensity was progressed based on pain status. and patients were not standardized.indd 24 4/17/2013 3:58:36 PM . there was no control group for comparison. at 2 years. All rights reserved. however.” The criterion for patients to be included in this study was more than a 50% motion restriction of the The effect of adding specific scapulothoracic glenohumeral joint in all directions for a period of 3 months or more. steroid injections) significantly improved in active abduction and external rotation ROM compared to the group taking Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Interestingly. included.24 Twenty-eight patients (7 males and 21 fe- active exercises up to and beyond the pain threshold. and function using the DASH. Inclusion past their pain threshold. Patients were the intense physical therapy group. Exercise ing the inflammatory stage. 2014. pain VAS. anterior/posterior and lateral radiographs. to do pendulum exercises and ac. Complete information was obtained for more than 81% of the participants at 3 months and 63% at 12 II and without steroid injection compared to the out- comes of patients who were just taking analgesics months. 10% (7/71) were and supplemented by a written daily program. had achieved a Constant score of at least 80 at the 1-year proprioceptive neuromuscular facilitation. Ninety percent (64/71) of instructed by a physical therapist over 2 therapy sessions the patients reported satisfactory outcomes. All patients were evaluated by an orthopaedist The “supervised neglect” group was instructed not to exercise and had both radiographs and MRI performed. and secondary frozen shoulder with score of greater than 80. 6. 32-65) years were Journal of Orthopaedic & Sports Physical Therapy® sive stretching. therapy group. The SDQ not satisfied. 95% CI: 0°. The Constant score was assessed every 3 months for II strengthening exercises to a physical therapy program was investigated in patients with adhe- 24 months. and to abduction. and the SF-36. ROM. transcutaneous follow-up. horizontal traumatic bone or tendon changes in the affected shoulder. A conclusion of this study was that aggressive The experimental group also performed isolated scapular therapy can be detrimental to some patients. neither the exercise program nor the analgesic medication was described. pas. Shoulder symptoms had diminished and functional motion had returned by 6 months Lee et al65 investigated the effect of exercise with after randomization. however. especially dur. a24 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines. The criteria for Downloaded from www. The intensive physical therapy group performed sive capsulitis. were treated for 6 weeks (30 sessions). exercises in forward elevation.jospt. and each group was treated 64% of the patients in the “supervised neglect” HEP group with active and passive ROM exercises. Interestingly. Patients were excluded if they had osteoarthritis. secondary fro- cant ROM and pain improvements. The HEP. and 4 patients were not available for was “restored”. The study demonstrated the equivalence of a thera. which included pendulum physical therapy for exercise performance. the manipulation were satisfied.1 (range. zen shoulder with type II impingement based on clinical tients in the “supervised neglect” group achieved a Constant examination and MRI. No other uses without permission. criteria were at least 50% restriction of external rotation. analgesics alone. adduction. although the patients 12 months. II outcome study that included 75 patients classified with stage 2 idiopathic adhesive capsulitis. and glenohumeral/scapular muscle strengthening. external rotation. All patients were referred to or a rotator cuff tear. and or arthroscopic release. scapulohumeral rhythm was only follow-up. normal resume all activities as tolerated. and the therapist exercises and stretching techniques for the shoulder. They found that most of the improvement II tients with idiopathic adhesive capsulitis to com- pare the effects of “intensive” physical therapy to occurred in the first 3 weeks. A modified Constant score.

They found that 89. and in an additional 37.4% of patients with a combina- B capsulitis in stretching exercises.5% of 98 patients with adhesive capsu. toms with nonoperative care or choosing operative care. and 1 or more injections. End points were satisfactory resolution of symp. Downloaded from www. For personal use only. Clinicians should instruct patients with adhesive litis responded to nonoperative management. The intensity of the exercises should be determined by the patient’s tion of physical therapy and nonsteroidal anti-inflammatory tissue irritability level.indd 25 4/17/2013 3:58:37 PM .org at on May 7. 2014.8 months. Resolution of symptoms occurred in 52. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. physical therapy. Adhesive Capsulitis: Clinical Practice Guidelines Levine et al68 reported on a nonoperative-care.1% of patients with a IV retrospective case series that included a standard physical therapy program with nonsteroidal anti- combination of nonsteroidal anti-inflammatory medication. medication. No specific program injection. Journal of Orthopaedic & Sports Physical Therapy® journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a25 43-05 Guidelines. All rights reserved. No other uses without permission. of exercise was described.jospt. The average time inflammatory medication with or without corticosteroid to successful treatment was 3.

diagnosing tissue irritability levels. ultrasound. active shoulder ROM.jospt. who are not responding to conservative interventions. female. Clinicians may utilize translational manipulation under anesthesia di- tions aimed at normalization of the patient’s impairments of body rected to the glenohumeral joint in patients with adhesive capsulitis function.indd 26 4/17/2013 3:58:38 PM . short-term (4-6 weeks) pain relief and improved function compared tinuum of pathology characterized by a staged progression of pain to shoulder mobility and stretching exercises alone. Intra-articular corticosteroid injections combined with shoulder B CLINICAL COURSE mobility and stretching exercises are more effective in providing Clinicians should recognize that adhesive capsulitis occurs as a con. and plan. or impairments of body function and structure are not consistent with the diagnosis/classification section of these guidelines. cal stimulation combined with mobility and stretching exercises to skeletal disorders. reduce pain and improve shoulder ROM in patients with adhesive ning intervention strategies for patients with shoulder pain and capsulitis. and have had a previous episode of adhesive capsulitis in the contralateral arm. 2014. particularly external rotation with the arm at the side and in function over the episode of care. function and structure. All rights reserved. Clinicians should recognize that (1) patients with diabetes mellitus body structures in patients with adhesive capsulitis. litis present with a gradual and progressive onset of pain and loss of active and passive shoulder motion in both elevation and C INTERVENTIONS – MODALITIES rotation. joint accessory motion may be assessed to determine translational and (2) adhesive capsulitis is more prevalent in individuals who are glide loss. and participation restric- tions associated with adhesive capsulitis. the ASES. differential evaluation of common shoulder musculo. Adhesive Capsulitis: Clinical Practice Guidelines CLINICAL GUIDELINES Summary of Recommendations E PATHOANATOMICAL FEATURES EXAMINATION – ACTIVITY LIMITATION AND F Clinicians should assess for impairments in the capsuloligamentous PARTICIPATION RESTRICTION MEASURES complex and musculotendinous structures surrounding the shoulder Clinicians should utilize easily reproducible activity limitation and complex when a patient presents with shoulder pain and mobility participation restriction measures associated with their patient’s deficits (adhesive capsulitis). Clinicians should utilize patient education that (1) describes the natural course of the disease. such Clinicians should instruct patients with adhesive capsulitis in stretch- as the DASH. A EXAMINATION – OUTCOME MEASURES B INTERVENTIONS – STRETCHING EXERCISES Clinicians should use validated functional outcome measures. though many patients report B INTERVENTIONS – PATIENT EDUCATION minimal to no disability. These should be utilized before ing exercises. of stretching to the patient’s current level of irritability. and passive C RISK FACTORS shoulder ROM to assess the key impairments of body function and Downloaded from www. E EXAMINATION – PHYSICAL IMPAIRMENT MEASURES Clinicians should measure pain. is a significant finding that can be used to guide treatment planning. C INTERVENTIONS – JOINT MOBILIZATION F DIFFERENTIAL DIAGNOSIS Clinicians may utilize joint mobilization procedures primarily directed Clinicians should consider diagnostic classifications other than to the glenohumeral joint to reduce pain and increase motion and adhesive capsulitis when the patient’s reported activity limitations function in patients with adhesive capsulitis.org at on May 7. and (3) matches the intensity Journal of Orthopaedic & Sports Physical Therapy® Clinicians should recognize that patients with adhesive capsu. a26 | may 2013 | volume 43 | number 5 | journal of orthopaedic & sports physical therapy 43-05 Guidelines. activity limitations. pain-free ROM. The intensity of the exercises should be determined by and after interventions intended to alleviate the impairments of body the patient’s tissue irritability level. The loss of passive motion in multiple shoulder pain to assess the changes in the patient’s level of shoulder planes. mobility deficits. mild to moderate mobility deficits and pain may persist. 40 to 65 years of age. or the SPADI. Utilizing the evaluation and intervention components described in these guidelines will assist clinicians in medical Clinicians may utilize shortwave diathermy. and mobility deficits and that. at 12 to 18 months. or C INTERVENTIONS – TRANSLATIONAL MANIPULATION when the patient’s symptoms are not resolving with interven. or electri- screening. varying degrees of shoulder abduction. No other uses without permission. Glenohumeral and thyroid disease are at risk for developing adhesive capsulitis. (2) promotes activity modification to F DIAGNOSIS/CLASSIFICATION encourage functional. For personal use only. A INTERVENTIONS – CORTICOSTEROID INJECTIONS Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®.

Ontario. Michener.upenn.com mcclure@arcadia. Pennsylvania Medical College of Virginia Phoenix.edu Associate Professor Lexington. California Glenside. PC Los Angeles. MSPT University of the Pacific College of Health Sciences Coordinator of Sports Rehabilitation Stockton. MD Clinic Director Champion Sports Medicine Assistant Professor Professor of Medicine MVP Physical Therapy Physiotherapy Associates Department of Physical Therapy Division of Rheumatology Federal Way.com Department of Physical Medicine Good Shepherd Penn Partners Tim L.com lamichen@vcu.net Philip McClure. Arizona torburn@yahoo. Adhesive Capsulitis: Clinical Practice Guidelines AFFILIATIONS AND CONTACTS AUTHORS Northeastern University David Geffen School of Medicine Paula M.com kwilkpt@hotmail. MA McMaster University Therapies Professor Hamilton. School of Medicine Director of Post-Professional Paul J. Pennsylvania Associate Professor Todd Davenport. DPT and Physical Therapy Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Alabama Bouvé College of Health Sciences and Immunology aferland@mvppt.jospt. Georgia Catalyst Sports Medicine John E.edu j. Washington Birmingham.seitz@neu.ca ICF-based Clinical Practice Guidelines and Clinics Therapy Coordinator Iowa City. PhD Roy D. PhD john.edu Department of Rehabilitation George J. Iowa Armstrong Atlantic State James W. For personal use only. California Program in Physical Therapy Musculoskeletal Team Leader journals@royaltman.com Division of Biokinesiology Surgery and Rehabilitation John DeWitt. Kuhn. DPT. PhD Columbus.edu Director. Virginia helenefearon@fearonlevine. Wisconsin Associate Professor Associate Professor of Orthopaedic jw@eipconsulting. Shaffer.dewitt@osumc. Kelley. DPT.edu Kevin Wilk. DPT Journal of Orthopaedic & Sports Physical Therapy® REVIEWERS Amanda Ferland.edu University President and Clinic Director La Crosse. DPT a. MEd. Seitz.kuhn@vanderbilt. PT. Canada Joseph J. Inc michael-shaffer@uiowa. Godges. Ohio Lori A. MA University of Iowa Hospitals Graduate Program in Physical macderj@mcmaster. DPT University of Minnesota martin. DPT Silhouette Consulting. DPT Associate Clinical Director Amee L. PhD University of Southern California Vanderbilt University Programs Physical Therapy Specialists. Wisconsin icf@orthopt. Michigan godges@usc. DPT Downloaded from www. PT.edu Leslie Torburn.indd 27 4/17/2013 3:58:38 PM .kelley@uphs. PT. PhD Boston.edu The Ohio State University thebosspr@comcast. All rights reserved. Orthopaedic Section. Ludewig.edu Michael A. DPT Professor Professor Principal and Consultant Department of Physical Therapy Department of Physical Therapy Helene Fearon. California Joy MacDermid. 2014. Altman. DPT. PT. PhD & Rehabilitation Philadelphia. PhD University of Kentucky University of Iowa Sports Medicine tdavenport@pacific.org at on May 7. No other uses without permission. Musculoskeletal Laboratory Associate Professor Minneapolis. Roubal. Kentucky Clinical Specialist School of Rehabilitation Science tluhl2@uky.com journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | a27 43-05 Guidelines.edu Richmond. PT.davies@armstrong. Massachusetts at UCLA Associate Professor Martin J.org Savannah. APTA. MD george. DPT. California Nashville. Tennessee Clinical Assistant Professor Troy. Uhl. Matheson. Inc Arcadia University Virginia Commonwealth University. Fearon & Levine Consulting San Carlos.edu Hudson.edu Los Angeles. Minnesota Department of Rehabilitation Science Department of Physical Therapy ludew001@umn. Davies.

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and Jeanne Robertson. a panel of experts developed a set of The condition affects between 2% and 5% of the population at treatment guidelines for improving the quality of care for people some point in their lives.43(5):A1-A31. to a progressive loss of motion (“freezing”) and limited function Frozen shoulder can also be linked to other health problems such of the shoulder over several months. mobility and stretching exercises. 2013 issue of JOSPT. with Deydre S. NEW INSIGHTS The expert panel recommends that patients learn about the symptoms that suggest they have frozen shoulder. 2014. JOSPT strives to offer high-quality research. These guidelines are published in the May 40 and 65 years of age.indd 351 4/17/2013 4:02:41 PM . JOSPT PERSPECTIVES FOR PATIENTS is a public service of the Journal of Orthopaedic & Sports Physical Therapy. getting dressed. PT. help you better understand the condition and. or reaching into a cabinet. For more information on the management of this condition. stiffness can limit your ability to do simple everyday activities like the condition starts to “thaw” and shoulder motion and function Downloaded from www. jospt perspectives for patients Frozen Shoulder What Can a Physical Therapist Do for My Painful and Stiff Shoulder? J Orthop Sports Phys Ther 2013. visit JOSPT Perspectives for Patients online at www. brushing your hair.jospt. Editor. customize a treatment program For this and more topics. and useful supplemental information on musculoskeletal and sports-related health. injury. With this condition. refers People with frozen shoulder usually experience an initial period to a condition where the shoulder becomes painful and characterized by an achy shoulder at rest. help speed up your healing. JOSPT Perspectives for Patients may be photocopied noncommercially by physical therapists and other healthcare providers to share with patients.2013.org at on May 7. titled “Shoulder Pain and Mobility decrease the pain and improve the motion and function Deficits: Adhesive Capsulitis. a time when there is often as diabetes and thyroid disease. There are a number of treatment options FROZEN SHOULDER TREATMENTS. No other uses without permission.jospt. participation in a good treatment program that combines education. Your physical therapist can tions to get you on the road to recovery. and joint mobilizations performed by your physical therapist can help manage symptoms and lead to faster Journal of Orthopaedic & Sports Physical Therapy® recovery of your shoulder motion and function. A thorough performed by physical therapists—joint mobilization evaluation will help define the right treatment approach for your shoulder. Heat and other treatments applied to the shoulder can also make mobility and stretching exercises more effective. among them—to your physical therapist will help determine the right combination of stretching and mobility exercises and joint mobiliza. contact your physical therapist or healthcare provider specializing in musculoskeletal disorders. also known as adhesive capsulitis. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. and difficulty sleeping because of shoulder pain. the pain and less pain but greater difficulty performing daily tasks. making sure you continue to move your shoulder the proper amount is key to your recovery. and the timeline for recovery. after a thorough evaluation. Teyhen. The official journal of the Orthopaedic Section and the Sports Physical Therapy Section of the American Physical Therapy Association (APTA). severe pain with move- stiff. For more information on the treatment of frozen shoulder. doi:10.org. In addition. and rehabilitation. For personal use only. and heat. exercise. PhD.0503 F rozen shoulder. that will include exercises for you to perform at home to This JOSPT Perspectives for Patients is based on an article by Kelley MJ et al. your physician may suggest a corticosteroid injection for your shoulder. contact your physical therapist This Perspectives article was written by a team of JOSPT’s editorial board and staff. The information and recommendations contained here are a summary of the referenced research article and are not a substitute for seeking proper healthcare to diagnose and treat this condition. doi:10.0302. of your shoulder.2013. PRACTICAL ADVICE If you have frozen shoulder. Recently. In addition to education on the condition. It may occur following a relatively minor injury to the ment. This leads shoulder but most often develops without a clear reason. gradually return.2519/jospt. The combination of an injection with joint mobilizations followed by mobility and stretching exercises has been found to be helpful. Several treatment options are available to address frozen shoulder. All rights reserved. Illustrator. and typically occurs in adults between with frozen shoulder. Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy ® journal of orthopaedic & sports physical therapy | volume 43 | number 5 | may 2013 | 351 43-05 Perspectives. They also urge that patients continue to use the affected shoulder during daily activities. or manipulation. Finally. specializing in musculoskeletal disorders.43(5):351.” J Orthop Sports Phys Ther 2013. immediately applicable clinical material. The problem usually lasts 1 to 2 years.2519/jospt. what to expect as the condition progresses. Eventually.

Clinical Rheumatology . [Abstract] [Full Text] [PDF] [PDF Plus] 6. 92-101. Journal of Orthopaedic & Sports Physical Therapy 44:1. Current evidence on physical therapy in patients with adhesive capsulitis: what are we missing?. Timothy W. December 2013 Letter to the Editor-in-Chief. JOSPT at 35. 2013. Journal of Orthopaedic & Sports Physical Therapy 43:9. 2013. Flynn. 2013. [CrossRef] 4. Paula M. 2014. Philip Paul Tygiel. Journal of Orthopaedic & Sports Physical Therapy® . Braman. For personal use only. Simoneau. 934-936. Derek Clewley. Lawrence. [Citation] [Full Text] [PDF] [PDF Plus] 5. 3-5.org at on May 7. September 2013 Letter to the Editor-in-Chief. Journal of Orthopaedic & Sports Physical Therapy 43:5. 2014. Filip Struyf. [Abstract] [Full Text] [PDF] [PDF Plus] [Supplemental Material] 2.jospt. [Abstract] [Full Text] [PDF] [PDF Plus] Downloaded from www. 2014. 280-283. No other uses without permission. Edith Holmes. 675-678. 2013. [Abstract] [Full Text] [PDF] [PDF Plus] 3. This article has been cited by: 1. Mira Meeus. Ludewig. What's in a Name? Using Movement System Diagnoses Versus Pathoanatomic Diagnoses. Journal of Orthopaedic & Sports Physical Therapy 43:12. Guy G. Jonathan P. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. Shane Koppenhaver. All rights reserved. Journal of Orthopaedic & Sports Physical Therapy 44:2. Trigger Point Dry Needling as an Adjunct Treatment for a Patient With Adhesive Capsulitis of the Shoulder. Rebekah L.