Shoulder Conditions:

Frozen Shoulder
Frozen Shoulder
- also known as “Adhesive Capsulitis”
- loss of active & passive ROM due to soft
tissue contracture.
- caused by adhesive fibrosis and scarring bet.
the capsule
 Frozen Shoulder Early Signs and
Symptoms

- Insidious onset of localized pain often

extending down the arm.
- Subjective report of stiffness, night pain,
restricted ROM in a capsular pattern.
Relevant
Anatomy/
Physiology
● Most mobile segment of
the human body
● Mobility is provided by
six moving areas
● Support and stabilization

TRUE JOINT FALSE JOINT

GH joint ST joint

AC joint

SC joint

Magee, D. J. (2014). Orthopedic physical assessment. Elsevier Health Sciences.

GH joint
A. Type: Multiaxial, ball &
socket, synovial joint
B. Articulation: Glenoid
cavity & humeral head

C. Ligaments: Superior,
middle & inferior GH
ligament,
coracohumeral
ligament & transverse
ligament
D. Kinematics:
Flexion/extension,
Abd/add, IR/ER
Magee, D. J. (2014). Orthopedic physical assessment. Elsevier Health Sciences.
RESTING POSITION 40° to 55° abduction, 30° horizontal
adduction (scapular plane)

CLOSED PACKED POSITION Full abduction & Lateral rotation

CAPSULAR PATTERN Lateral rotation, abduction, medial rotation

Magee, D. J. (2014). Orthopedic physical assessment. Elsevier Health Sciences.

Labrum - Ring of fibrocartilage that surrounds and deepens the glenoid cavity of
the scapula for about 50%

Rotator Cuff Muscles (SITS) – depression of humeral head and maintain contact
and in center glenoid cavity

Ligaments
• Superior GlenoHumeral Ligament (SGHL)
- Limits inferior translation in adduction
- Restrains anterior translation and lat. Rot up to 45° abd

Magee, D. J. (2014). Orthopedic physical assessment. Elsevier Health Sciences.

• Middle GlenoHumeral Ligament (MGHL)
- Limits lat. Rot up to 45° to 90°

• Inferior GlenoHumeral Ligament (IGHL)

- Most important. Beyond 90° limits inferior translation of the humeral head
- Anterior band, axillary pouch, posterior band
⃰ In between SGHL & MGHL- Foramen of Weitbrecht

⃰ In between MGHL & IGHL- Foramen of Rouvier

• Coracohumeral Ligament
- Limits inferior translation
- Helps limit ER below 60° abd

Magee, D. J. (2014). Orthopedic physical assessment. Elsevier Health Sciences.

• Transverse Humeral Ligament
- Forms the roof of bicipital groove

Magee, D. J. (2014). Orthopedic physical assessment. Elsevier Health Sciences.

Rotator Interval - Injury to the structures within the rotator interval can lead to
contractures, biceps tendon instability, anterior GH instability.

● Coracohumeral ligament
● SGHL
● GH joint capsule
● Tendon of supraspinatus and subscapularis

Magee, D. J. (2014). Orthopedic physical assessment. Elsevier Health Sciences.

RANGE OF MOTION

Motion Normal Values

Shoulder Flexion 0 – 180 ⁰

Shoulder Extension 0 - 60 ⁰

Shoulder Abduction 0 - 180 ⁰

Shoulder Internal Rotation 0 - 70 ⁰

Shoulder External Rotation 0 - 90

SPECIAL TEST/s
- Neer’s Test
- Hawkin’s Kenny Test
- Drop Arm Test
- SLAP test/ o’brien test
- Empty Can Test
- Apley Scratch Test
- Lift off test
EPIDEMIOLOGY
● Sex incidence unremarkable; more common in women
between 40-60 y/o
● Several studies have shown that the diagnosis is 2 to 4
times more common in diabetic patients than in the
general population

Kingston, K., Curry, E. J., Galvin, J. W., & Li, X. (2018). Shoulder adhesive capsulitis: Epidemiology and predictors of
surgery. Journal of Shoulder and Elbow Surgery, 27(8), 1437–1443. https://doi.org/10.1016/j.jse.2018.04.004
RISK FACTORS
● Diabetes Mellitus

● Thyroid disorder

● Stroke

(Wang et al., 2013)

RED FLAGS

Mcclure, Philip & Michener, Lori. (2014). Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder). Physical therapy. 95. 10.2522/ptj.20140156.
PATHOPHYSIOLOGY
- Unknown
- Most common accepted hypothesis : inflammation initially occurs within
the joint capsule and synovial fluid and followed by reactive fibrosis and
adhesions of the synovial lining of the joint, which can lead to pain, and the
capsular fibrosis and adhesions lead to a decreased range of motion.

- Lundberg introduce the term primary and secondary term to it.

Primary: idiopathic onset and no detectable underlying cause
Secondary: can be classified into intrinsic, extrinsic and systemic
● Inflammatory process such as:
a. Supraspinatus tendinitis
b. Subacromial bursitis
c. Tenosynovitis of long heads of biceps
d. Acromioclavicular arthritis
e. Impingement syndrome
f. RSD
CLINICAL PHASES OF FROZEN SHOULDER
Freezing Phase (Acute)
- Duration: 2 – 9 months
- Gradual onset of shoulder pain
- Pain at rest: painful movement
- Nagging constant pain that is worse at night; sleep interruption
Adhesive Phase (Frozen)
- Duration: 4 – 12 months
- Pain gradually subsides but stiffness remain
- Progressive loss of GH motion in capsular pattern
- Apparent pain only at extreme motions
 - More difficult to complete ADLs
- Gross reduction of glenohumeral movements with near total loss of
lateral (external) rotation.

Thawing Stage (Recovery)

- Spontaneous, progressive improvement in ROM (w/in 5-24 mos)
- Mean duration from onset of frozen shoulder to greatest resolution
exceeds 30 weeks
ETIOLOGY
● Idiopathic or Primary
● Direct/Indirect trauma to the shoulder
● Referred pain from cardiac or nerve root affectation. This is due to the
common link of the heart & shoulder especially the left (embryonic
origin).
DIFFERENTIAL DIAGNOSIS

Acromioclavicular Arthropathy
Distinguishing Physical Examination
-Positive cross-arm adduction and compression testing; glenohumeral
range of motion is preserved
Distinguishing Historical Findings
-Localizes over acromioclavicular joint (superiorly); history of repetitive
overuse (e.g., weight lifting)
Diagnostic Test
-Plain radiographyrigin).
Biceps Tendinopathy
Distinguishing Physical Examination
- Tenderness over long head of the biceps tendon;
positive Speed or Yergason test
Distinguishing Historical Findings
- Localizes anteriorly
Diagnostic Test
- MRI (radiography may determine whether
calcifications are present)
•Glenohumeral osteoarthritis
Distinguishing Physical Examination
- Similar to adhesive capsulitis; shoulder girdle atrophy
may be present
Distinguishing Historical Findings
- History of shoulder trauma or surgery; older age
Diagnostic Test
- Plain radiography
Cervical disk degeneration
Distinguishing Physical Examination
-Limited range of motion in neck and pain with active
movement; intrinsic hand weakness;
impaired light touch
Distinguishing Historical Findings
- Localizes posteriorly; hand numbness and weakness in
radiculopathy
Diagnostic Test
- Cervical spine radiography
Rotator cuff tendinopathy or tear, with or
without impingement.
Distinguishing Physical Examination
- Passive range of motion is preserved; painful arc, focal
tenderness, positive Hawkins and Neer
tests
Distinguishing Historical Findings
-Possible history of repetitive overuse; often localizes anteriorly
or laterally
Diagnostic Test
- MRI (radiography may determine whether calcifications are
present)
Subacromial and subdeltoid bursitis
•

Distinguishing Physical Examination

- Passive range of motion is preserved
Distinguishing Historical Findings
- Possible history of repetitive overuse
Diagnostic Test
- Diagnostic subacromial lidocaine (Xylocaine)
injection, MRI
ICF
PHARMACOLOGICAL INTERVENTION
Non steroidal anti-inflammatory drugs (NSAIDS):
- Ibuprofen (Advil®, Motrin®)
- Acetaminophen (Tylenol®)
- Diclofenac (Voltaren, Cataflam, Lopena)

Other painkiller/anti-inflammatory drugs may be prescribed by doctor

For most severe pain and swelling:

- can be managed by steroid injections

Corticosteroid (Cortisone)
- injected directly into the shoulder joint (sub-acromial & intra articular)
SURGICAL and other intervention
Arthroscopic Capsular Release (Arthroscopic Arthrolysis)
- Cutting and removing of thickened, swollen, inflamed
capsule

Manipulation under anesthesia (MUA)

- Controlled and forced, end-range positioning of humerus
relative to flexion, abduction, rotation with an anesthetic
block to brachial plexus w/c allows shoulder muscles to
completely relax

Translation Mobilisation under Anesthesia

- Use of gliding techniques with static end range capsular stress
with a short amplitude high velocity thrust
ASSESSMENT TOOL
Shoulder Pain and Disability Index (SPADI)
- a questionnaire with 13 items assessing pain level and extent of
difficulty with ADLs requiring the use of the upper extremities. The pain
subscale has 5-items and the Disability subscale has 8-items

Disability of the Arm, Shoulder and Hand Scale (DASH)

- a 30 item, self report questionnaire that measures physical
function and symptoms in people with musculoskeletal disorders of the upper
limb.

VAS (Visual Analog Scale)

PT MANAGEMENT

- Transcutaneous Electrical Nerve Stimulation (TENS)

- Passive Joint Mobilization with Capsular Stretching

Exercises

- Home Exercises Program

PT GOALS
- Achieved appropriate level of muscle recruitment for low and
high loads for the shoulder.

- Balanced recruitment of muscle groups of the shoulder ( in

terms of strength, timing and coordination)

- Restoration of normalized recruitment pattern

- Restore motor control during isometric, concentric and

eccentric muscle activity.
REFERENCES:
Wang, K., Ho, V., Hunter-Smith, D. J., Beh, P. S., Smith, K. M., & Weber, A. B. (2013). Risk factors in
idiopathic adhesive capsulitis: A case control study. Journal of Shoulder and Elbow Surgery, 22(7).
https://doi.org/10.1016/j.jse.2012.10.049

Kingston, K., Curry, E. J., Galvin, J. W., & Li, X. (2018). Shoulder adhesive capsulitis:
Epidemiology and predictors of surgery. Journal of Shoulder and Elbow Surgery, 27(8), 1437–
1443. https://doi.org/10.1016/j.jse.2018.04.004

Khan, W. S., Dillon, B., Agarwal, M., Fehily, M., & Ravenscroft, M. (2009). The validity, reliability,
responsiveness, and bias of the Manchester-Modified Disability of the Arm, Shoulder, and Hand
score in hand injuries. Hand, 4(4), 362-367.

Williams, N. (2014). Dash. Occupational medicine, 64(1), 67-68.

Ewald, A. (2011). Adhesive capsulitis: a review. American family physician, 83(4), 417-422.
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