Adhesive Capsulitis
IMPAIRMENT/FUNCTION-BASED DIAGNOSIS




Prevalence
o Higher prevalence of diabetes and hypothyroidism among pts with adhesive
capsulitis (AC)
Pathoanatomical features
o GH capsule, coracohumeral ligament and GH ligaments comprise
capsuloligamentous complex
 This complex, along with the RC tendons, create intimate static and
dynamic sleeve
 The proximal portion of the capsuloligamentous complex and the
subscapularis were found to limit ER when the GH joint was positioned up
to 45° of abduction
 Subscap limited ER the most with arm at 0 degrees abd
o Adhesive capsulitis is marked by multiregional synovitis
 Also nerve growth in the complex, which may add to pain, at rest or with
motion
 The entire complex can become fibrotic, but the RC are involved
 Anterior restricts ER w arm at side, posterior restricts IR
 Coracohumeral ligament release resulted in increase in ER
o Clinicians should asses for impairments- loss of passive ROM in mult planes, esp
ER and abd is imp
Risk Factors
o Elevates serum cytokine levels
o Type 1 or 2 diabetes mellitus
o Thyroid disease (mostly women)
 Inc hypothyroidism and hyperthyroidism
o Age (age 40-65)
o Having it on one side inc risk for other side
o Prolonged immobilization
o MI, autoimmune disease
o **Pts with diabetes and thyroid disease are at risk for developing AC
Clinical Course
o 4 stages of AC
o Stage 1
 Up to 3 months, sharp pn at end range, achy at rest, sleep disturbance
 Min to no ROM restrictions, and subacromial impingement is often
thought bc of it
 Loss of ER with intact RC is a hallmark sign
o Stage 2
 “painful” or “freezing” stage, gradual loss of ROM in all directions bc of
pn
 3-9 months
o Stage 3



 “frozen stage”
 capsuloligamentous fibrosis results in loss of ROM under anesthesia
o Stage 4
 “thawing” stage
 pn begins to resolve, stiffness persists 15-24 months after symptom onset
o In the research, vast majority of pts were satisfied with their outcome, but 40%
still reported residual shoulder disability
 Conservative treatment and surgical tx were both successful
o AC occurs as a continuum of pathology, characterized by staged progression of
pn and mobility deficit
 At 12-18 months, mild pn and deficit may persist
Diagnosis/Classification
o Diagnosis
 Determined from hx and physical exam
 Pts present with gradual onset of pn, restricted ROM in elevation and
rotation
 Purpose of dx: direct intervention and inform prognosis
 Pn and ROM less post op is NOT AC
o Classification
 Global loss of AROM and PROM
 Greater than 25% in 2+ planes, and PROM loss ER >50% =AC
 ER motion loss is greater than Abd
 MMT is sometimes painless, sometimes painful
o Component 1
 Medical screening- uses hx and phys exam to determine if pt symptoms
are MSK disorder or more serious, like tumor
 Should also screen for psychosocial issues, which can affect prognosis
o Component 2
 Pts with shoulder pn often fi more than 1 impairment, most relevant
impairment changes during pt’s episode of care
o Component 3
 Dx of tissue irritability is imp- guides tx freq, intensity, duration, type
 Irritability = tissue’s ability to handle physical stress
 3 levels- determined by relation ptwn pn and AROM and PROM
o Component 4
 Should match most app intervention to level of irritability
 High irrit- tx should emphasize activity modification and appro. modalities
 Mod irrit- controlled physical stress (manual therapy, stretching)
Differential Dx
o 3 most common shoulder conditions: adhesive capsulitis, sprain/strain shoulder
joint/dislocation, RC syndrome,
o but lots of others!
o Clinicians should remember there’s more conditions than AC
Imaging
o Imaging can be used to rule out underlying pathology
 Ex GH osteoarthritis
o MRI can identify soft tissue and bony abnormalities
EXAMINATION



Outcome measures
o Many out there, not all have demonstrated acceptable measurement properties
 Constant score, the DASH, the SPADI, and the ASES are widely used
o Constant score- most widely used in Europe
 2 sections- pt self report and a clinician report
 doesn’t comprehensively represent construct of shoulder use, only asks 4
questions about functional use
o ASES- pt self report
 100 pt, 50 pts for pn and 50 for activity
o DASH- pt self report
o SPADI- pt self report
 Had superior responsiveness when compared to DASH
o Clinicians should use valid outcome measures before and after interventions
Activity Limitations
o Clinicians should use easily reproduced activity and participation to assess pt
shoulder pn and to see changes over episode of care
Physical Impairment measures
o AROM and PROM should be measured- ER in add/abd, IR in abd, shoulder
flexion and abduction
INTERVENTIONS




Successful tx does not require full ROM
o Instead, may be defined as reduced pn, improved function, and high lvl of pt
satisfaction
Corticosteroid injections
o Not within PT scope of practice, but pts who get it normally see PTs too
o Reduce inflammatory response and pn in pts with AC
o Significant improvement in jt motion immed following steroid injections
Take home: intra-articular corticosteroid injections combined with shoulder mobility and
stretching exercises are more effecting in providing short-term pain relief and improved
function compared to shoulder mobility and stretching exercises alone
Patient education
o Central to each pt-PT interaction, critical to rehab management with pts with AC
 Describing pathology can allay fears and prep them for the progression
and recovery
 Encourage activity modification and emphasizing functional pain free
ROM is imp to prevent them from immobilizing their shoulder and
making it worse
o Pt education should: 1)describe the natural course of the condition, 2) promot
activity mod, and func pain-free ROM, and 3)match the intensity of stretching to
the pt’s level of irritability




Modalities
o Heat and electrical modalities can help with pain in the tx
o Impact of a single modality is hard to determine, since they’re typically applied
with adjunct tx to manual therapy and exercises
o Take home: clinicians can use short wave diathermy, ultrasound, or e-stim
combined with mobility and stretching to reduce pn and improm shoulder ROM
Joint Mobilization
o Evidence that it may be beneficial, but none to support it being better than other
interventions
 More research needs to be done
o Can improve motion and function while reduce pn
Translational manipulation
o Alternative tx to standard shoulder manipulation for unresponsive adhesive
capsulitis
 In study, 2 person manipulation- 1 person stabilized scapula whilt the
other performed translational manip
 6 of 8 experienced significant immed increase in PROM
o good idea to use anesthesia
Stretching exercises
o Influence pn and improve ROM but not more than other interventions
o Results are inconsistent across studies, and no evidence exists to guide optimal
freq, number of reps, or duration of stretching
 As in joint mobs, future research is needed
o Intensity of exercises should be determined by patient’s tissue irritability level.