Comparison of Restricted Movement Pattern Among Patients of Idiopathic,

Diabetic, and Traumatic Adhesive Capsulitis

A Critical Analysis
By Jhet Ardian Coritana

Adhesive capsulitis, also known as frozen shoulder, is a disabling and painful disorder
which makes the shoulder capsule, the connective tissue around the glenohumeral joint of the
shoulder to become stiff and inflamed. This condition greatly restricts motion and causes
chronic pain. Thus, restriction in adhesive capsulitis is known, however, pattern of restriction in
different groups of adhesive capsulitis is unknown and unclear. Although the exact
pathophysiologic cause of this pathology remains elusive, there are two types identified in this
study: idiopathic or primary adhesive capsulitis and secondary adhesive capsulitis. Idiopathic
“primary” adhesive capsulitis occurs spontaneously without a specific precipitating event.
Secondary adhesive capsulitis, on the other hand, occurs after a shoulder injury, surgery or
other severe articular trauma, or may be associated with another condition such as diabetes or
cardiovascular disease, which may prolong recovery and limit outcomes. Nonetheless, the study
was mainly focused on idiopathic, diabetic and traumatic group of Adhesive capsulitis.

The study aimed to investigate the frequency with which the shoulder pain in the society
in people with idiopathic, traumatic and adhesive capsulitis, is linked up with restriction of
movement and is there any particular movement that is more likely to be restricted than others.
It was also set to compare the pattern of restriction in shoulder range of motion among three
groups of patients aforementioned. Unlike the other studies, the study compared patients of
same pathology based on different cause. Comparative cross-sectional study was conducted by
the researchers on comparison of restricted movement pattern among patients with idiopathic,
diabetic and traumatic adhesive capsulitis using convenient sampling procedure to collect data
through a self-administered questionnaire and used a standardized Goniometer for the
measurement of ROM. In addition, patterns of restriction movement in analyzing the procedure
included: Shoulder Flexion, Shoulder Extension, Shoulder Abduction, Shoulder Internal Rotation
and Shoulder Internal Rotation.

Some studies claim that there are 20 to 50% patients with adhesive capsulitis that suffer
restriction issues and other problems that may remain for as long as 10 years and
approximately 70% of these patients are females. The researchers were able to prove a claim
supported by another study conducted by Sang et al, that the prevalence of Adhesive Capsulitis
is greater in women compare to men. However, they did not mention the risk for longer recovery
and greater disability in males with frozen shoulder.

It was also stated in the study that age is one of the major risk factors that will determine
if a person is susceptible to Adhesive Capsulitis. It was also mentioned that individuals who are
above 40 were most likely to produce this condition. A total of 60 patients calculated through,
were included in this study and divided into three groups with both female and male subjects,
age between 40-75. However, the author did not mention if the age of an individual determines
the severity of the condition.

In choosing the respondents of the study, the researchers considered patients who were
free from cancer, any systemic disease and any infection. Since the aim of the study focuses
more on patients of same pathology based on different cause, the researchers take into
consideration other factors that might affect the main purpose of the study including its medical
history since its critical to the diagnostic process and patient evaluation. Nonetheless, frozen
shoulder may also be confused with other clinical syndromes; therefore, it is important to have
an accurate differential diagnosis to rule out other pathologies.

The pattern for the glenohumeral joint proposed by Cyriax is that the proportional
passive loss of external rotation will be greater than the proportional loss of abduction, which will
be greater than the proportional loss of internal rotation. Results regarding patterns of ranges in
all groups showed that for flexion range of motion there was non-significant difference between
Idiopathic and Diabetic Group, while between Idiopathic versus Traumatic and Diabetic versus
Traumatic group it was significant. For extension range of motion, between Idiopathic and
Diabetic Group, there was non-significant difference, while it was significant for idiopathic versus
traumatic and diabetic versus traumatic groups. Results for abduction range of motion, there
was non-significant difference for all groups i.e. idiopathic versus diabetic, idiopathic versus
traumatic and traumatic versus diabetic. While for internal and external rotation groups of
idiopathic versus diabetic and idiopathic versus traumatic all showed significant difference and
non-significant for traumatic versus diabetic group for internal and external rotation.

Based on the results, the authors concluded that both diabetic and traumatic groups
have a capsular pattern as proposed by the Cyriax but this was not the case for the idiopathic
group of adhesive capsulitis. This is because one of the studies showed that the idiopathic
group had the most trouble in external rotation and abduction during the early stages of
Adhesive Capsulitis where they scored the lowest among the 3. It was also supported by
another research conducted by (Eto, 1999) who studied the abduction values also showed that
the idiopathic group scored the lowest among the 3 groups again. Another evaluation by (Terry
et al, 1999) about internal rotation in adduction was conducted and the idiopathic scored the
lowest among the groups again. The authors also concluded that there was not any particular
capsular pattern emerged. Nevertheless, it was also supported by the claim of Peter j.
Rundquist who conducted a study on shoulder kinematics in subjects with frozen shoulder.

As discussed in the study, idiopathic adhesive capsulitis patients have their joints
thickened and shortened and the collagen is packed more densely thus making it difficult to
move. Furthermore, Idiopathic adhesive capsulitis results from a chronic inflammatory response
with fibroblastic proliferation, which may actually be an abnormal response from the immune
system. This was the primary main reason on why the idiopathic group scored the lowest in
most of the studies conducted by the researchers thus resulting to the conclusion that diabetic
and traumatic groups of adhesive capsulitis followed cyriax ‘capsular pattern’ but in idiopathic
group of adhesive capsulitis this pattern did not emerged. Overall, the researchers were able to
established a different perspective in comparing restricted movements among patients with
Adhesive Capsulitis.