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clinical review

adhesive capsulitis

indexing Metadata/Description
        Title/condition: Adhesive Capsulitis Synonyms: Frozen shoulder, pericapsulitis, periarthritis, capsulitis, scapulohumeral periarthritis, periarthrosis humeroscapularis, idiopathic frozen shoulder, capsular syndrome Anatomical location/body part affected: Shoulder, shoulder capsule, coracohumeral ligament Description: Pain and stiffness of the shoulder ICD-9 codes 726.0 adhesive capsulitis of shoulder ICD-10 codes M75.0 adhesive capsulitis of shoulder Reimbursement: No specific issues or information regarding reimbursement have been identified Presentation/signs and symptoms: Progressive, severe pain and limitation of shoulder motion. Pain often radiates to the insertion of the deltoid. Pain at night and at rest are common in early stages

causes & Risk Factors

 Causes Primary: Idiopathic Secondary: From known cause; disuse, prolonged immobilization, etc. Narrowing of the subacromial space does not contribute to adhesive capsulitis (AC)(1) Pathogenesis: There is controversy in the literature regarding pathogenesis; unclear if the underlying cause is inflammatory or a fibrosing condition, or due to an algoneurodystrophic process.(1, 2) Contracture of the coracohumeral ligament occurs with progression of the disease(1) Three clinical stages Painful stage (freezing): 1036 weeks. ROM restrictions begin 23 weeks after onset of intense pain Adhesive stage (frozen): Pain only with movement. Significant ROM restrictions occur at this point. Atrophy of the deltoid, rotator cuff, biceps, and triceps may be evident Recovery stage (thawing): 224+ months. Pain is usually resolved but capsular restrictions and ROM restrictions still present Associated conditions Parkinsons disease Cardiac disease Pulmonary disease Stroke (mostly due to muscle spasticity) Dupuytrens disease Previous neck trauma Risk factors Risk factors for primary (idiopathic) AC(3) Autoimmune disease Recurrent hemarthrosis Muscular inactivity Period of immobilization of the shoulder Reflex sympathetic dystrophy (RSD) Risk factors for secondary AC(3) Intrinsic  Acromioclavicular arthritis  Rotator cuff tendinitis/tear Extrinsic  Cardiac disease/postsurgical  Post mastectomy  Stroke (hemiplegia)  Pulmonary disease

Joanne Minichillo, PT

Amy Lombara, RPT Cinahl Information Systems Glendale, California Rehabilitation Operations Council Glendale Adventist Medical Center Glendale, California

Sharon Richman, MSPT Cinahl Information Systems

October 10, 2008

Published by Cinahl Information Systems. Copyright2008, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206


 Shoulder/cervical trauma  Diabetes  Thyroid disease  Rheumatoid arthritis and scleroderma

Incidence and prevalence 2% of the general population 70% women Usually occurs after age 40; peak incidence at 56 years old 20-30% of patients will also develop AC in the contralateral shoulder Slightly more common in the nondominant arm 10-30% of patients with AC are diabetic

Overall contraindications/Precautions
  Aggressive stretching, exercise, or manipulation in the initial stage may worsen symptoms and possibly create permanent damage See specific Contraindications/precautions to examination and Contraindications/precautions under Assessment/Plan of Care

  Contraindications/precautions to examination: Use caution not to exacerbate symptoms during evaluation History History of present illness/injury Mechanism of injury or etiology of illness: Inquire about onset of pain, history of trauma, history of immobilization, any neurological symptoms Course of treatment  Medical management: If patient does not respond to conservative measures, other options include Closed manipulation under anesthesia Arthroscopic capsular release Open surgical capsular release Capsular distention  Medications for current illness/injury: Analgesics for pain, intra-articular steroid injections  Diagnostic tests completed Diagnosis is usually made from history and physical X-ray can be used to rule out other conditions such as arthritis, calcific tendonitis, etc. Ultrasonography can be used to rule out rotator cuff tear(4)  Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative therapies (e.g., acupuncture) and whether or not they help  Previous therapy: Document whether patient has had occupational or physical therapy for this or other conditions and what specific treatments were helpful or not helpful Aggravating/easing factors: Inquire about precipitating and relieving factors (and length of time each item is performed before the symptoms come on or are eased) Body chart: Use body chart to document location and nature of symptoms. Pain often radiates to the insertion of the deltoid Nature of symptoms: Patients may complain of severe pain and stiffness Rating of symptoms: Use a visual analog scale or 0-10 scale to assess symptoms at their best, at their worst, and at the moment (specifically address if pain is present now and how much) Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (AM, mid-day, PM, night); also document changes in symptoms due to weather or other external variables Sleep disturbance: Pain at night and at rest is common in early stages Other symptoms: Document other symptoms patient may be experiencing that could exacerbate the condition and/or symptoms that could be indicative of a need to refer to physician Barriers to learning  Are there any barriers to learning? Yes No  If Yes, describe _______________________ Medical history Past medical history  Previous history of same/similar diagnosis: Often a previous shoulder injury has occurred  Comorbid diagnoses: Is the patient diabetic? History of thyroid or autoimmune disease?  Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken (including over-thecounter drugs)  Other symptoms: Ask patient about other symptoms he/she may be experiencing

Social/occupational history Patients goals: Document what the patient hopes to accomplish with therapy and in general Vocation/avocation and associated repetitive behaviors, if any: Is the patient having difficulty with activities of daily living (ADL),
modifications necessary? Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be appropriate to patient medical condition, functional status, and setting) Circulation: Assess upper extremity pulses; should not be affected Gait/locomotion: Decreased arm swing may be present Joint integrity and mobility: Expect joint pain at end range and limited joint play of the glenohumeral joint Muscle strength: Assess only when ROM has been restored Observation/inspection/palpation Palpate for tenderness over the glenohumeral joint, scapula, trapezius, and rotator cuff muscles Tenderness is usually diffusepinpoint tenderness usually indicates other shoulder pathologies(5) Assess for atrophy of deltoid and supraspinatus muscles Posture: Assess for forward head, rounded shoulders, decreased arm swing, or other protective posturing (patients may hold arm in adduction and internal rotation) Range of motion Capsular restrictions begin in phase 2 Loss of external rotation is almost complete in true cases of AC(2) External rotation, abduction, and internal rotation limitations are the most prevalent Assess AROM in standing; patient may substitute scapular motion for glenohumeral motion (evident by shoulder shrugging) Assess glenohumeral motion with the patient in supine position; stabilize the scapula when testing Assess scapulothoracic motion Gross exam of cervical and thoracic spine and bilateral shoulders Self-care/activities of daily living: Assess if patient is having difficulty with home management, work activities, or sleep. Assess general ability to perform ADLs; is patient able to lift/carry, etc. Sensory testing: General assessment of sensation; should not be affected unless there is another pathology present

Living environment: With whom does patient live, caregivers, etc.; identify if there are barriers to independence in the home; any

work, or leisure activities?

assessment/Plan of care
 Contraindications/precautions Aggressive stretching, exercise, or manipulation in the initial stage may worsen symptoms and possibly create permanent damage If there is increased pain after ROM and joint mobilization, discontinue techniques or lessen the frequency, duration, and force Vigorous stretching techniques should not commence until inflammation has subsided(6) Contraindications to cryotherapy include Raynauds syndrome, medical instability, cryoglobulinemia, cold urticaria, and paroxysmal cold hemoglobinuria. Avoid applying cold over superficial nerves, areas of diminished sensation, poor circulation, or slow-healing wounds Precautions for cryotherapy Use caution with patients who are hypertensive as cold can cause a transient increase in blood pressure; discontinue treatment if there is an elevation in blood pressure Use caution with patients who are hypersensitive to cold Avoid aggressive treatment with cold modalities over an acute wound Use of cryotherapy with patients who have an aversion to cold may be counterproductive if being used to promote muscle relaxation and decrease pain(7) Contraindications to heating modalities include application over areas with decreased sensation, vascular insufficiency, recent or potential hemorrhage, malignancy, acute inflammation, or infection. Do not use heat over areas where heat rubs or liniments have been recently used. Do not use heat if unable to determine sensory deficits in patients with cognitive deficits or if a language barrier is present(7) Diagnosis/need for treatment: Physical therapy treatment needed for pain management in the initial stages, ROM and strengthening once pain has resolved Rule out If symptoms are bilateral (or other joints are involved) and include fever, fatigue, or morning stiffness, suspect inflammatory disorder or infection If trauma preceded AC, suspect fracture or rotator cuff pathology Suspect arthritis if onset was gradual and worsened with time Prognosis A prospective study with 41 patients found at 5 and 10 years that 39% of patients had a full recovery 54% had limitations in ROM and strength but no impact on function 7% had residual functional limitations(2)


Recurrence is unusual

Referral to other disciplines: Orthopedist Treatment summary: Physical therapy in the initial stage focuses on decreasing pain and inflammation. Once pain has resolved, begin gradual progression of ROM and strengthening exercises Expected Progression


Decrease pain

Physical agents and mechanical modalities Heat and/or ice as needed for pain Electrotherapeutic modalities No evidence to suggest that ultrasound is effective to treat pain(8)

Home Program
Instruct patient in pain management techniques

Decreased ROM

Restore normal ROM

Therapeutic exercises Codman (pendulum) exercises, climb the wall, posterior capsule stretch, towel stretch Manual therapy High-grade mobilization techniques (HGMT) are slightly more effective than low-grade mobilization techniques (LGMT) in increasing active and passive external rotation and overall glenohumeral joint mobility(9) Posterior glide technique may increase external rotation more effectively than anteriorly directed force(11) Soft tissue massage may help to increase ROM(12)

Therapeutic exercises Physical therapy consisting of muscle stretching, spinal mobilization, and exercises combined with arthrographic distension of the glenohumeral joint with saline and corticosteroid improves range of motion but does not improve pain, function, or quality of life according to a randomized trial with 156 adult patients with AC(10)

Advise patient to perform exercises (Codman [pendulum] exercises, climb the wall, cross arm [posterior capsule] stretch, towel stretch) with the noninvolved shoulder as well Encourage patient to reach for items during ADL with affected arm

Decreased ability to perform ADL

Restore normal ADL

Manual therapy ERM and MWM may be more effective than MRM in increasing function(13) Functional training Address ADL deficits

Progress based on individual patient needs; consider patients age and physical impairments


Decreased strength

Increase strength

Therapeutic exercises Begin with isometric strengthening exercises of the shoulder, scapular, and elbow muscles

Therapeutic exercises Once ROM has been restored, the patient can begin resistive exercises with weights or Theraband Closed chain (quadruped progress to tripod) and plyometric exercises may help to increase ROM and strength(14)

Instruct patient to perform exercises with the uninvolved arm as well as the elbow, wrist, and fingers of the involved arm

Decreased scapulohumeral rhythm

Improve scapulohumeral rhythm

Manual therapy Mobilization with movement (MWM) may be more effective in increasing scapulohumeral rhythm compared to end-range mobilization (ERM) and midrange mobilization (MRM). ERM and MWM may be more effective than MRM in increasing function(13)

Expected Progression
Therapeutic exercises Scapular stabilization and scapulohumeral rhythm retraining

Home Program
Continue prescribed exercises at home

Desired Outcomes/Outcome Measures

Desired outcomes include improved function, normalized shoulder ROM and upper extremity strength. Outcome measures include goniometry, manual muscle testing, and Shoulder Disability Index.

Maintenance or Prevention
Avoid prolonged immobilization.

coding Matrix
References in this Clinical Review are rated using the following codes, listed in order of strength: M Published meta-analysis SR Published systematic or integrative literature review RCT Published research (randomized controlled trial) R Published research (not randomized controlled trial) C Case histories, case studies G Published guidelines RV Published review of the literature RU Published research utilization report QI Published quality improvement report L Legislation PGR Published government report PFR Published funded report PP Policies, procedures, protocols X Practice exemplars, stories, opinions GI General or background information/texts/reports U Unpublished research, reviews, poster presentations or other such materials CP Conference proceedings, abstracts, presentations

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Sheridan MA, Hannafin JA. Upper extremity: emphasis on frozen shoulder. Orthop Clin North Am. 2006;37(4):531-539. (GI) Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ. 2005 Dec 17;331(7530):1453-1456. (RV) Aly, N. Frozen shoulder syndrome; an enigma. Geriatr Med. 2005; 35(3):61-62, 64, 66-68. (GI) Teefey SA, Hasan SA, Middleton WD, Patel M, Wright RW, Yamaguchi K. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am. 2000;82(4):498-504. (R) DynaMed Editorial Team. Adhesive capsulitis. DynaMed Web site. Updated September 2, 2008. Accessed October 9, 2008. (RV) Schrepfer R. Aquatic exercise. In: Kisner C, Colby LA. Therapeutic Exercises; Foundations and Techniques. 5th ed. Philadelphia, PA: FA Davis Company; 2007:289. (GI) Michlovitz SL, Nolan TP. Modalities for Therapeutic Intervention. 4th ed. Philadelphia: F.A. Davis Company; 2005. (GI) van der Heijden GJ, van der Windt DA, de Winter AF. Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomised clinical trials. BMJ. 1997;315(7099):25-30. (S) Vermeulen HM, 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;86(3):355-368. (RCT) Buchbinder R, Youd JM, Green S, et al. Efficacy and cost-effectiveness of physiotherapy following glenohumeral joint distension for adhesive capsulitis: a randomized trial. Arthritis Rheum. 2007;57(6):1027-1037. (RCT) Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis. J Orthop Sports Phys Ther. 2007;37(3):88-99. (RCT) Wiles, J. Treatment of eight patients with frozen shoulder: a case series. J Bodywork Movement Ther. 2005; 9(1):58-64. (C) Yang JL, Chang CW, Chen SY, Wang SF, Lin JJ. Mobilization techniques in subjects with frozen shoulder syndrome: randomized multipletreatment trial. Phys Ther. 2007;87(10):1307-1315. (RCT) Liebenson, C. Self-management of shoulder disorderspart 3: treatment. J Bodywork Movement Ther. 2006;10(1):65-70. (GI)