ADHESIVE CAPSULITIS

Definition/Description

Adhesive capsulitis is a benign, self-limiting condition of unknown etiology

characterised by painful and limited active and passive glenohumeral range of
motion of ≥ 25% in at least two directions , most notably shoulder abduction and
external rotation.

Adhesive capsulitis, commonly referred to as frozen shoulder, is associated

with synovitis and capsular contracture of the shoulder joint and can be classified
as either primary or secondary.

Epidemiology /Etiology

Glenohumeral Joint

Although the etiology remains unclear,

adhesive capsulitis can be classified as

 primary or
 secondary.

Frozen shoulder is considered primary if the onset is idiopathic while secondary

results from a known cause or surgical event.

Three subcategories of secondary frozen shoulder include:

 systemic (diabetes mellitus and other metabolic conditions),

 extrinsic (cardiopulmonary disease, cervical disc, CVA, humerus
fractures, Parkinson’s disease), and
  intrinsic factors (rotator cuff pathologies, biceps tendinopathy, calcific
tendinopathy, AC joint arthritis.

Gender: more prevalent in women than men(women> men,

Age: 40-65 years old

Adhesive capsulitis is often in the diabetic population, with an occurrence rate of

approximately 2-5% in the general population, and 10-20% of the diabetic
population.

If an individual has adhesive capsulitis they have a 5-34% chance of having it in

the contralateral shoulder at some point. Simultaneous bilateral involvement has
been found to occur in approximately 14% of cases.

Other associated risk factors include:

o trauma,
o prolonged immobilisation,
o thyroid disease,
o stroke,
o myocardial infarcts, and
o presence of autoimmune disease. ]

The disease process affects the anteriosuperior joint capsule, axillary recess, and
the coracohumeral ligament.

It has been shown through arthroscopy that patients tend to have a small joint
with loss of the axillary fold, tight anterior capsule and mild or moderate synovitis
but no actual adhesions.

Contracture of the rotator cuff interval has also been seen in adhesive capsulitis
patients, and greatly contributes to the decreased range of motion seen in this
population.

There is continued disagreement about whether the underlying pathology is an

inflammatory condition, fibrosing condition, or an algoneurodystrophic process.
Evidence suggests there is synovial inflammation followed by capsular fibrosis, in
which type I and III collagen is laid down with subsequent tissue contraction.

Elevated levels of serum cytokines have been noted and facilitate tissue repair and
remodeling during inflammatory processes. In primary and some secondary cases
of adhesive capsulitis cytokines have shown to be involved in the cellular
mechanism that leads to sustained inflammation and fibrosis. It is proposed that
there is an imbalance between aggressive fibrosis and a loss of normal collagenous
 remodeling, which can lead to stiffening of the capsule and ligamentous
structures.

Characteristics/Clinical Presentation

Patients presenting with adhesive capsulitis will often report an insidious onset
with a progressive increase in pain, and gradual decrease in active and passive
range of motion.

Patients frequently have difficulty with grooming, performing overhead activities,

dressing, and particularly fastening items behind the back.

The literature reports that adhesive capsulitis progresses through three

overlapping clinical phases:

 Acute/freezing/painful phase:

gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and
pain at night with sleep interruption.

Duration: from 3-9 months.

 Adhesive/frozen/stiffening phase:

Pain starts to subside, progressive loss of glenohumeral motion in capsular

pattern. Pain is apparent only at extremes of movement.

Duration: around 4 months - till about 12 months.

 Resolution/thawing phase:

Spontaneous, progressive improvement in functional range of motion

Durarion: last from 1 - 3.5 years.

Differential Diagnosis

Osteoarthritis (OA). Both may have limited abduction and external rotation
AROM but with OA, PROM will not be limited. OA will also present with the most
limitations with flexion whereas this is the least affected motion with adhesive
capsulitis. Radiography can be used to rule out pathology of osseous structures.

Bursitis. Bursitis presents very similarly to adhesive capsulitis, especially

compared to the early phases. Patients with bursitis will present with a non -
traumatic onset of severe pain with most motions being painful. A main difference
will be the amount of PROM achieved. Adhesive capsulitis will be extremely
limited and painful whilst patients with bursitis, although painful, will have a
larger PROM.

Parsonage-Turner Syndrome (PTS). PTS occurs due to inflammation of the

brachial plexus. Patients will present without a history of trauma and with painful
restrictions of all motions. The pain with PTS usually subsides much quicker than
with adhesive capsulitis and patients eventually display neurological problems
(atrophy of muscles or weakness) that are seen several weeks after the initial
onset of pain.

Rotator Cuff (RC) Pathologies. The primary way to distinguish RC pathologies

from adhesive capsulitis is to examine the specific ROM restrictions. Adhesive
capsulitis presents with restrictions in the capsular pattern while RC involvement
typically does not. RC tendinopathy may present similarly to the first stage of
adhesive capsulitis because there is limited loss of external rotation and strength
tests may be normal. MRI and ultrasonography can be used to identify soft tissue
abnormalities of the soft tissue and labrum.

Posterior Dislocation. A posteriorly dislocated shoulder can present with shoulder

pain and limited ROM, but, unlike adhesive capsulitis, it is related to a specific
traumatic event. If the patient is unable to fully supinate the arm while flexing the
shoulder, the clinician should suspect a posterior dislocation.

"Active Muscle Guarding" Hollmann et al. (2015) reported in their study that all
of the patients suspected to have Frozen Shoulder showed a significant increase in
range of motion under anesthesia, which confirms that some cases might have
been falsely diagnosed with Frozen Shoulder and that the loss of range of motion
cannot only explained by capsular contractions.

Examination

The following outcome measures have been used in studies researching adhesive
capsulitis.

 Shoulder Pain and Disability Index (SPADI)

 Disability of the Arm, Shoulder and Hand scale (DASH)
 American Shoulder and Elbow Surgeons (ASES)
 Simple Shoulder Test (SST)
 Penn Shoulder Scale (PSS)
 NPRS
 VAS
 SF-36
 Observation of posture and positioning

 Scapular winging of the involved shoulder may be observed from the

posterior and/or lateral views.

Screen: Upper quarter exam (UQE) and neuro screen (dermatomes, myotomes, reflexes)

 A full UQE should be performed to rule out cervical spine involvement or any
neurological pathologies.

Rom screen: Active/passive/overpressure

Cervical, thoracic, shoulder ROMs with OP as well as rib mobility should be

performed.

 Scapular substitution frequently accompanies active shoulder motion. [2]

Resisted muscle tests

Shoulder external rotation (ER)/ Internal rotation (IR)/abduction (ABd) (seated)

should be performed.

Patients with adhesive capsulitis present with weakness in shoulder ER, IR and ABd
relative to the asymptomatic side.

Foraml ROM: Active/passive/overpressure

Shoulder Flex/ABd/ER/IR

 Patients with adhesive capsulitis commonly present with ROM restrictions in a

capsular pattern. A capsular pattern is a proportional motion restriction unique to
every joint that indicates irritation of the entire joint. The shoulder joint has a
capsular pattern where external rotation is more limited than abduction which is
more limited than internal rotation (ER limitations > ABD limitations > IR
limitations).
 Joint accessory mobility

Glenohumeral joint:

 Anterior
 Inferior
 Posterior
 Posterior capsule stretch

In patients with adhesive capsulitis, the anterior and inferior capsule will be the
most limited but joint mobility will be restricted in all directions.

Special tests

Shoulder Shrug Sign

Yang et al. investigated the reliability of 3 function related tests in patients with
shoulder pathologies via a non-experimental study

Hand to neck

 Shoulder flexion + abduction + ER

 Similar to ADLs such as combing hair, putting on a necklace

Hand to scapula (Figure 1B)

 Shoulder extension + adduction + IR

 Similar to ADLs such fitting a bra, putting on a jacket, getting into back pocket

Hand to opposite scapula (Figure 1C)

 Shoulder flexion + horizontal adduction

These tests require appropriate elbow, scapulothoracic, and thoracic mobility and
these areas should be cleared of pathology first. If a patient is unable to complete
the motion, other structures outside of the shoulder joint may be the limiting
factor.

Reliability of the three tests was excellent and correlation between them
was moderate. [25]

These functional measures appear to be helpful for their objectivity in measuring

shoulder dysfunction. However, even though the tests mimic fundamental ADL
 movements, the direct relationship between these tests and activities of daily
living cannot be assumed.

Other

No specific clinical test for adhesive capsulitis has been reported in the literature
and there remains no gold standard to diagnose adhesive capsulitis. [7] While there
are no confirmed diagnostic criteria, a recent study determined a set of clinical
identifiers that achieved a general consensus amongst experts for the early stages
of primary (idiopathic) adhesive capsulitis. [7] The following tools can be used to
help determine the stage of adhesive capsulitis and/or its irritability status.

Consensus was achieved on eight clinical identifiers collated into two discrete
domains (pain and movement) as well as an age component.[7]

Pain

 Strong component of night pain

 Pain with rapid or unguarded movement
 Discomfort lying on the affected shoulder
 Pain easily aggravated by movement

Movement

 Global loss of active and passive ROM

 Pain at end-range in all directions

Onset

 > 35 years of age

Medical Management

Although Adhesive Capsulitis is a self-limiting condition, it can take up to two to

three years for symptoms to resolve and some patients may never fully regain full
motion. Treatment for pain, loss of motion, and limited function rather than take
the wait-and-see approach is therefore important. Various interventions have
been researched that address the treatment of the synovitis and inflammation and
modify the capsular contractions such as oral medications, corticosteroid
injections, distension, manipulation, and surgery. Even though many of these
treatments have shown significant benefits over no intervention at all, definitive
management regimens remain unclear. It is suggested that the primary treatment
for adhesive capsulitis should be based around physical therapy and anti-
inflammatory measures, these outcomes, however, are not always superior to
other interventions.

Corticosteroid Injections

Corticosteroid injections are often used to manage inflammation as it is

understood that inflammation is a key factor in the early stages of the condition.
The injections aim to reduce the painful synovitis occurring within the
shoulder.[2][5] This can limit the development of fibrosis and adhesions within the
capsule, potentially shortening the natural history of the
disease. [5][1] Hence they are thought to be more useful in the early, painful and
freezing stage of the condition due to the involvement of inflammation, rather
than in the latter stages when fibrous contractures are more apparent. [3][14][1][27]

Methyl-prednisolone and Triamicinolone have both been found to be effective for

injection use. There is no evidence suggesting the most effective treatment dose or
administration site. The majority of the studies, however, used 20-40 mg injected
via an anterior or posterior approach. [14]

Many studies have been performed and reviewed comparing corticosteroid

injections to physical therapy, but results have been contradictory. It has been
concluded that corticosteroid injections provide significantly greater short term
benefits (4-6 weeks), especially in pain relief, but there is little to no difference in
outcomes by 12 weeks compared to physical therapy. [3][5][2][14][27][28] The majority
of studies, however, investigating corticosteroid injection as a treatment option do
not define what stage the patients are in and had variations in the vol umes of
corticosteroid used. It has been shown that the benefits may not only be dose
dependent, but also dependent on the duration of symptoms as
well. [14][1] Therefore, the earlier the injection is received, the quicker the
individual will recover. Contraindicationsto corticosteroids use include a history
of infection, coagulopathy, or uncontrolled diabetes. [14]

Ultimately, corticosteroid injections have been shown to have success rates

ranging from 44-80%[3] with rapid pain relief and improved function occurring
mainly in the first weeks of treatment. It is a first line treatment for patients with
pain as their predominant complaint in the early stages of adhesive
capsulitis.[5][2] Though intra-articular steroid injection may be beneficial early on,
its effect may be small and not well maintained [28] and should be offered in
conjunction with physical therapy. [5][14]

Recommendations:
 Injection for relieving shoulder disability and pain and physical therapy for
improving motion in the painful freezing stage. [2][1]
 If patients fail to progress within 3-6 weeks with physical therapy alone or patient's
symptoms worsen, they should be offered the option of a corticosteroid injection. [2]

Manipulation under anesthesia (MUA)

Manipulation under anesthesia involves a controlled and forced, end range

positioning of the humerus relative to the glenoid in physiologic planes of motion
(flexion, abduction, rotation) in patients with an anesthetic block to the brachial
plexus. The block allows the shoulder muscles to completely relax so that the force
may actually reach the capsuloligamentous structures. [2]Traditionally, long lever
arms were used, but now short lever arm techniques are utilised to minimise
potential risks. [2][9] Although success rates are high, ranging from 75-
100%,[2] manipulations are considered a last resort and are not indicated unless
symptoms persist in spite of adequate conservative treatment for six
months.[1][2][3][27] This is due to the numerous risks and complications such as:
dislocation, glenoid, scapular, or humeral fracture, nerve palsy, rotator cuff tear,
hemarthrosis, labral tears, and traction injuries of the brachial plexus or a
peripheral nerve. [1][2][3][27] However, it has been shown that manipulations are the
most reliable way to improve range of motion and reduce pain and disability in
patients resistant to physical therapy [1][3] and these complications can be
minimised with proper techniques and precautions. A good prognosis is often
indicated if an audible and palpable release of the tissue occurs during the
manipulation. [2]

An extensive post-manipulation programme begins immediately after release of

the capsule.[2][9] They are often prescribed active assisted range of motion
exercises that should be performed every two hours during waking hours, for the
next 24 hours. Patients are also instructed to ice their shoulder for 20 minutes
every two hours with their hand resting behind their head. Post manipulation
programs are designed to maintain gains in shoulder mobility and should
specifically address each individual's impairments. [2][9]

Contraindications to manipulation under anesthesia include: history of fracture or

dislocations, moderate bone loss, or an inability to follow through with post
procedure care. [2] Although manipulation under anesthesia has been shown to be
effective in improving function and motion in patients with adhesive capsulitis,
more randomised controlled trials comparing this treatment to competing
treatments before widespread use are needed. [9]

Translation mobilisation under anesthesia

 An alternative to traditional MUA is translation mobilisation under anesthesia,
which has been identified in an attempt to avoid the complications associated
with the traditional approach. This procedure involves the use of gliding
techniques with static end range capsular stress with a short amplitude high
velocity thrust, if needed, as opposed to the angular stretching forces in
manipulation under anesthesia. [2][9]2 to 3 30 second sets of low velocity,
oscillatory mobilisations (Maitland Grade IV-IV+) are performed initially in the
same directions as traditional manipulation under anesthesia (anteriorly,
posteriorly, and inferiorly). If an immediate increase in passive range of motion is
not seen, a high velocity, low amplitude manipulation may be performed. This
technique appears to be a safe and efficacious alternative for treatment of patients
resistant to conservative treatment, however, higher level studies are needed for
verification. [2]

 If a patient has persistent symptoms, particularly in decreased shoulder motion,

after at least 6 months of conservative treatment, manipulation under anesthesia is
an effective technique to improve mobility, pain and disability.
 Contraindications and complications do exist and should be relayed to the patient.

[29]

Arthroscopic capsular release

Arthroscopic capsular release is the preferred method over open release in

patients with painful, disabling adhesive capsulitis that is unresponsive to at least
6 months of non-operative treatment. It has been found to be a reliable and
effective method for restoring range of motion and is especially recommended for
diabetics and in post-operative or post-fracture adhesive capsulitis patients. [3][1] It
has become the most popular method of treating non-responsive adhesive
capsulitis despite the lack of higher level trials comparing it to MUA. [27] This is
because it allows a more controlled and selective release of the contracted capsule
compared to manipulation which ruptures the capsuloligamentous structures and
avoids the complications associated with MUA.[2][1] Debate exists over which
structures should be arthroscopically released with the rotator cuff and
coracohumeral ligament being the most common structures released. [2]

Recommendations:
  If patient is unresponsive to at least 6 months of conservative treatment,
arthroscopic capsular release alone or in conjunction with manipulation has been
shown to be effective in restoring range of motion.
 Avoids complications associated with manipulation under anesthesia and is
recommended in diabetics and post-operative or post-fracture adhesive capsulitis
patients.

Other

Non-steroidal anti-inflammatory drugs (NSAIDs) have traditionally been given to

patients with adhesive capsulitis, but there is no high level evidence that confirms
their effectiveness.[1][27]

Oral steroids have also been utilised in these patients and result in some
improvement in function, but their effects have not shown long term benefits and
combined with their known adverse side effects, should not be regarded as a

[31]

routine treatment.[1][27][30]

Another technique that shows some short term benefit with rapid relief of
symptoms is distension arthrography. This technique involves the injection of a
solution (saline alone or combined with corticosteroids) causing rupture of the
capsule by hydrostatic pressure. [3] It is still undetermined whether joint
distension with saline solution combined with corticosteroids provides more
benefit than distension with saline alone or corticosteroid injection alone. [3] There
is a lack of reliable evidence when determining the effectiveness of this technique
and further research needs to be performed to verify any clinical benefit. [3][27][32]

Suprascapular nerve blocks are thought to temporarily disrupt pain signals to

allow normalisation of the pathological, neurological processes perpetuating pain
and disability. [27] There is some evidence of benefit with suprascapular nerve
blocks, though the exact mechanism behind this benefit remains unclear and
higher level evidence is needed to establish this as a treatment for adhesive
capsulitis.

According to a Cochrane review by Green et al,[33] there is little evidence to

support or refute the use of any of the common interventions listed for adhesive
capsulitis. There are also no studies with objective data supporting the timing of
when to switch to invasive treatments such as manipulation under anesthesia or
arthroscopic release which are not usually performed until 6 months of
conservative treatment have been unsuccessful. Unfortunately this exposes more
than 40% of patients with adhesive capsulitis to a long period of disability. [3]

Treatment should be tailored to the stage of the disease because the condition has
a predictable progression. [1][27]During the painful freezing stage, treatment should
be directed at pain relief with pain guiding activity. NSAIDs, physical therapy and
steroid injection are all suggested interventions during this stage of adhesive
capsulitis.[14][1] Once the patient is in the adhesive stage, injections are no longer
indicated because the inflammatory stage of the disease has passed. The focus
should instead switch to more aggressive stretching and MUA or surgical release
if symptoms are unresponsive to conservative treatment and quality of life is
compromised.[1][2][3][27]

Physical Therapy Management

The definitive treatment for adhesive capsulitis remains unclear even though
multiple interventions have been studied. Previously published prospective
studies of effective treatment have demonstrated conflicting results for improving
shoulder range of motion in patients with this condition. [34](LoE: 4) Non-
operative interventions include patient education, modalities, stretching
exercises, and joint mobilisations. [2](LoE: 5) [4](LoE: 1a) Levine et al.reported
that 89.5% of ninety eight patients with frozen shoulder responded well to non -
operative management. [2](LoE: 5) Reviewed studies suggest that many patients
have benefited from physical therapy and showed reduced symptoms, increased
mobility, and/or functional improvement. [4](LoE: 1a) A
Cochrane Review by Green et al, however, states that there is no evidence that
physiotherapy alone is of benefit for adhesive capsulitis. [33](LoE: 1a)

Importance of patient education

For the treatment of adhesive capsulitis, patient education is essential in helping

to reduce frustration and encourage compliance. It is important to emphasise that
although full range of motion may never be recovered, the condition will
spontaneously resolve and stiffness will greatly reduce with time. It is also helpful
to give quality instructions to the patient and create an appropriate home exercise
program that is easy to comply with as daily exercise is critical in relieving
symptoms.[2](LoE: 5)

Modalities

Modalities, such as hot packs, can be applied before or during treatment. Moist
heat used in conjunction with stretching can help to improve muscle extensibility
and range of motion by reducing muscle viscosity and neuromuscular mediated
relaxation.[2](LoE: 5) In a randomised study by Bal et al., patients improved with
combined therapy which involved hot and cold packs applied before and after
shoulder exercises were performed.[5](LoE: 1b) However, Jewell et al, claimed
that ultrasound, massage, iontophoresis and phonophoresis reduced the chances
of positive outcomes. [11](LoE: 2b) Green et al. suggested that there is no evidence
of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis
or rotator cuff tendinitis. [33](LoE: 1a)

Initial Phase: painful, freezing

As alluded to, treatment should be customised to each individual based on the

stage of the condition.

Pain relief should be the focus of the initial phase, also known as the painful,
freezing Phase. During this time, any activities that cause pain should be avoided.
Better results have been found in patients who performed simple pain free
exercise, rather than intensive physical therapy [1](LoE: 3a) In patients with high
irritability, range of motion exercises of low intensity and short duration can alter
joint receptor input, reduce pain, and decrease muscle guarding. Stretches may be
held from one to five seconds in a pain free range, 2 to 3 times a day. [2](LoE: 5) A
pulley may be used to assist range of motion and stretch, depending on the
patient’s ability to tolerate the exercise. Core exercises include pendulum exercise,
passive supine forward elevation, passive external rotation with the arm in
approximately 40 degrees of abduction in the plane of the scapula, and active
assisted range of motion in extension, horizontal adduction, and internal
rotation.[2](LoE: 5)

Although performed on a single patient only, Ruiz et al performed positional

stretching of the coracohumeral ligament in the initial phase of adhesive
capsulitis.[34](LoE: 4) The patient's Disabilities of Arm Shoulder and Hand
(DASH) scores improved from 65 to 36 and Shoulder Pain and Disability Index
(SPADI) scores improved from 72 to 8 and passive external rotation increased
from 20 to 71 degrees. The stretches performed focused on providing positional
low load and prolonged stretch to the CHL and the area of the rotator interval
capsule following anatomical fibre orientation. The rationale behind this was to
produce tissue remodelling through gentle and prolonged tensile stress on the
restricting tissues. While a cause and effect relationship cannot be inferred from a
single case, this report may help with further investigation regarding therapeutic
strategies to improve function and reduce loss of range of motion in the shoulder
and the role that the CHL plays in this. [34](LoE: 4)

In the case of adhesive capsulitis, physical therapy can also be a complement to

other therapies (such as steroid injections as discussed previously), especially to
improve the range of motion of the shoulder. [3](LoE: 3a) Bal et alsuggested that
concomitant exercises to steroid injections should include isometric
strengthening in all ranges once motion returned to 90% of normal ranges,
theraband exercises in all planes, scapular stabilisation exercises, and later,
advanced muscular strengthening with dumbbells. [5](LoE: 1b)

Second Phase: adhesive

During the adhesive phase, the focus of treatment should be shifted towards more
aggressive stretching exercises in order to improve range of motion. The patient
should perform low load, prolonged stretches in order to produce plastic
elongation of tissues and avoid high load, brief stretches, which would produce
high tensile resistance. [1](LoE: 3a)

A prospective study by Griggs et al, demonstrated success of a non-operative

treatment through a four-direction shoulder stretching exercise programme in
which 90% of the patients reported a satisfactory outcome. [3](LoE: 3a)During
the second phase of treatment, movement with mobilisation and end range
mobilisations are recommended. [12](LoE: 1b) Mobilisation with movement can
also correct scapulohumeral rhythm significantly better than end range
mobilisation. The goal for end range mobilisation is not only to restore joint
range, but also to stretch contracted peri-articular structures, whereas
mobilisation with movement aims to restore pain free motion to the joints that
had antalgic limitation of range of motion. [12](LoE: 1b)

Gaspar and Willis.[8](LoE: 2b) demonstrated that physical therapy paired with
dynamic splinting had better outcomes compared to physical therapy alone or
dynamic splinting alone. The patients in this group of combined treatments
received physical therapy twice a week and a Shoulder Dynasplint System
(SDS) for daily end range stretching. The combination of physical therapy
with dynamic splinting had significant improvements in active, external rotation
in patients with adhesive capsulitis. [8](LoE: 2b)

Third Phase: resolution

During stage three, treatment is progressed primarily by increasing stretch

frequency and duration, whilst maintaining the same intensity, as tolerated by the
patient. The stretch can be held for longer periods and the sessions per day can be
increased. As the patient’s irritability level reduces, more intense stretching and
exercises using a device, such as a pulley, can be performed to influence tissue
remodelling. [2](LoE: 5)

Manual Techniques
Mechanical changes that occur as a result of mobilisations may include the break -
up of adhesions, realignment of collagen, or increased fibre glide when specific
movements stress certain parts of the capsular tissue. These techniques are
intended to increase joint mobility by inducing changes in synovial fluid
formation. High grade mobilisation techniques (HGMT) have been shown to be
helpful for improving range of motion in patients with adhesive capsulitis for at
least three months. [10](LoE: 1b) In a study by Vermeulen et al., patients were
given inferior, posterior, and anterior glides as well as a distraction to the
humeral head. These techniques were performed at greater elevation and
abduction angles if glenohumeral joint range of motion increased during
treatment. Patients who received HGMT received these mobilisations at Maitland
Grades III and IV according to the subjects' tolerance with the intention of
treating the stiffness. Patients were allowed to report a dull ache as long as it did
not alter the execution of the mobilisations or persist for more than four hours
after treatment. However, patients who received low-grade mobilisation
techniques (LGMT) at Mailtand Grades I or II reported no pain. Statistically
significant greater change scores were found in the HGMT group for passive
abduction (at 3 and 12 months) and for active and passive external rotation (at 12
months) when compared with the low-grade mobilisation techniques. High grade
mobilisation techniques appear to be more effective for increasing joint mobilit y
and reducing disability. [10](LoE: 1b) Further studies are needed, however, to
investigate whether HGMTs applied during earlier stages of adhesive capsulitis
are as effective.[10](LoE: 1b)

Johnson et al. reported that joint mobilisations, in particular posterior

glenohumeral glides, can help decrease deficits in external rotation, more so than
anterior glenohumeral glides. [22](LoE: 1b) Both techniques had a significant
decrease in pain, but there was greater improvement in external rotation range of
motion with the posterior mobilisation treatment. [22](LoE: 1b) End range
mobilisation is also more effective than mid-range mobilisation in increasing
motion and functional mobility. [12](LoE: 1b) Overall, there are significant
beneficial effects of joint mobilisation and exercise for patients with adhesive
capsulitis.[11](LoE: 2b)

Rationale for stretching

Research regarding connective tissue stretch duration and intensity has produced
3 findings. Firstly, that high intensity, short duration stretching aids the elastic
response, whilst low intensity, prolonged duration stretching aids the plastic
response. Secondly, a direct correlation exists between the resulting proportion of
plastic, permanent elongation and the duration of a stretch. Lastly, a direct
correlation exists between the degree of either trauma or weakening of the
stretched tissues and the intensity of a stretch. McClure et al, stated that the
maximum TERT (Total End Range Time) or the total amount of time the joint is
held at near end range position, will be different for each person and is often
affected by personal circumstances such as their job or other responsibilities that
may prevent a patient from increasing TERT. [34](LoE: 4)

Progression

Manual techniques and exercise should only be progressed as the patient’s

irritability reduces. Patient response to treatment should be based on their pain
relief, improved satisfaction, and functional gains, rather than restoration of
range of motion. Usually, patients are discharged when significant pain reduction
is reached, a plateau of motion gains are noticed for a period of time, and after
improved functional motion and satisfaction have reached their peak. [2](LoE:
5) Progression for stretching via dynamic splinting is based on patient tolerance,
as well. Gaspar and Willis, suggested that if patients experience discomfort or
stiffness lasting more than an hour after the splint is removed, the duration of
treatment is reduced for the next two stretching sessions. Only after stretching for
a total of 60 minutes (30 minutes twice a day) is tolerated, is it suggested that the
tension is then increased, every two weeks based on tolerance, without discomfort
lasting more than one hour following every stretching session. [8](LoE: 2b)

Despite extensive research, further prospective randomised studies comparing

different treatments are needed to formulate precise guidelines about diagnosis
and treatment of idiopathic adhesive capsulitis. [3](LoE: 3a) The lack of validity,
poor standardisation of terminology, methodology, and outcome measures in the
investigations undermines clinical application. Therefore, more rigorous
investigations are needed to compare the cost and effectiveness of physical
therapy interventions. [4](LoE: 1a)

Rehabilitation protocol for adhesive capsulitis

File:Rehabilitation Protocol for Adhesive Capsulitis.doc [2][34][1][5][12][10][8]

Key Research

Vermeulen HM1, Rozing PM, Obermann WR, le Cessie S, Vliet Vlieland TP.
Comparison of high-grade and low-grade mobilization techniques in the
management of adhesive capsulitis of the shoulder: randomized controlled trial,
Phys Ther. 2006 Mar;86(3):355-68

Blanchard V, Barr S, Cerisola FL, 2010, The effectiveness of corticosteroid

injections compared with physiotherapeutic interventions for adhesive capsulitis:
a systematic review, Physiotherapy. 2010 Jun;96(2):95-107.
Cleland J, Durall C, 2002, Physical therapy for adhesive capsulitis: A systematic
review, Physiotherapy August 2002Volume 88, Issue 8, Pages 450–457

Resources

FIgure 1: Forward Flexion; External Rotation; Extension

Figure 2: Internal Rotation; Horizontal Adduction; Pulleys for Elevation

Figure 3: Coracohumeral Ligament Stretch

Figure 4: Elevation and ER with Cane

Figure 5: Posterior Mobilizations

Figure 6: Anterior Mobilizations

Description and scoring of the 3 function-related tests for the first stage of primary
adhesive capsulitis. (Adapted from Yang et al, 2002, Reliability of function-related tests
in patients with adhesive capsulitis, JOSPT, 36, p.573)

Hand-to-neck (shoulder flexion + external rotation)*

0 The fingers reach the posterior median line of the neck with the shoulder in full
 abduction and external rotation without wrist extension.

1 The fingers reach the median line of the neck but do not have full abduction and/or
external rotation.

2 The fingers reach the median line of the neck but with compensation by adduction in
the horizontal plane or by shoulder elevation

3 The fingers touch the neck

4 The fingers do not reach the neck

Hand-to-scapula (shoulder extension + internal rotation)¤

0 The hand reaches behind the trunk to the opposite scapula or 5cm beneath it in full
internal rotation

1 The hand almost reaches the opposite scapula, 6-15 cm beneath it

2 The hand reaches the opposite illiac crest

3 The hand reaches the buttock

4 Subject cannot move the hand behind the trunk

Hand-to-opposite scapula (shoulder horizontal adduction)§

0 The hand reaches to the spine of the opposite scapula in full adduction without wrist
flexion

1 The hand reaches to the spine of the opposite scapula in full adduction

2 The hand passes the midline of the trunk

3 The hand cannot pass the midline of the trunk

* This test measures an action essential for daily activities, such as

using the arm to reach, pull, or hang an object overhead or using the
arm to pick up and drink a cup of water.

¤ This test measures an action essential for daily activities, such as

using the arm to pull an object out of a back pocket or tasks related
to personal care.

§ This test measures an action important for daily activities, such as

using the arm to reach across the body to get a car's seat belt or
using the arm to turn a steering wheel.
Clinical Bottom Line
There is no definitive treatment for adhesive capsulitis. However, the literature
suggests interventions should be tailored to the stage of the disease based on its
progressive nature. During the initial/painful freezing stage, treatment should be
directed at pain relief with pain guiding activity. NSAIDs and steroid injection,
stretching, strengthening and range of motion exercises, as well as Maitland
Grade I-II mobilisations have been shown to improve function and reduce pain
and disability. As the patient progresses to the adhesive stage, intervention should
focus on aggressive, end-range stretches combined with Maitland Grade III-IV
mobilisations. At six months, if functional disability persists despite conservative
treatment, mobilisations under anaesthesia (MUA) or arthroscopic capsular
release may be indicated.