MEDICAL BACKGROUND ON

ADHESIVE CAPSULITIS

SUBMITTED BY:

MERCADO
MARCELLO
GURTIZA
PIOQUINTO
I. Introduction

Adhesive capsulitis
 is a syndrome defined in its purest sense as idiopathic painful restriction of shoulder
movement that results in global restriction of the glenohumeral joint. It is not associated
with a specific underlying condition. It has also been described as a condition of
"unknown etiology characterized by gradually progressive, painful restriction of all joint
motion . . . with spontaneous restoration of partial or complete motion over months to
years.
 The first reported description of frozen shoulder was made by Duplay in the late
1800s.They used the label scapulohumeral periarthritis to describe a broad spectrum of
pathologies of the shoulder that resulted to pain, stiffness, and dysfunction. This label
served as an umbrella term that encompassed disorders such as rotator cuff tendonitis
ad tears, biceps tendonitis and tears, calcific deposits, AC arthritis, and other painful
shoulder syndromes.
 The term frozen shoulder was later coined in 1934 by Codman, who characterized the
condition as involving a slow onset, pain near the deltoid insertion, inability to sleep on
the affected side, painful and restricted elevation and lateral rotation, and a normal
radiological appearance.
 Codman described the condition as “difficult to define, difficult to treat and difficult to
explain from the point of view of pathology”.
 Lundberg introduced the terms primary and secondary further describe frozen
shoulders in 1969. Primary frozen shoulder, are those with idiopathic onset, whereas
secondary frozen shoulders occur following trauma and or immobilization. Secondary
frozen shoulders have been further classified into intrinsic, extrinsic, and systemic
categories by Zuckeman and Rokito.
 Naviaser describes adhesive capsulitis as a distinct entity with four identifiable stages
that are arthroscopically distinct:
 Stage 1 (painful stage)
- Shoulder motion is restricted little if at all during this stage.
- Arthroscopy shows an erythematous fibrinous pannus over the
synovium, primarily around the dependent fold.
- The articular cartilage is normal in condition
- Duration of symptoms: 0-3 months
 Stage 2 (freezing stage)
- Characterized by pain with associated loss of motion in all planes
- Arthroscopically, the synovium appears red, thickened, and inflamed.
- Adhesions across the dependent fold can be seen.
- There is loss of the space between the humeral head and glenoid as
well as between the humeral head and biceps tendon.
- Duration of symptoms:3-9 months
 Stage 3 (frozen stage)
- Characterized by the transition from inflammatory synovitis to chronic
fibrosis and by markedly decreased size of the dependent fold.
- There is complete obliteration of the space between the humeral head
and biceps tendon.
 - Duration of symptoms:9-15 months
 Stage 4 (thrawing stage)
- There is no longer synovitis present
- The dependent fold has become severely contracted by this stage
- Shoulder motion s severely limited.
- Duration of symptoms:15-24 months
II. Epidemiology
 Prevalence of frozen shoulder
- is 2% to 5% in the general population
- 10%-20% in patient with diabetes.
 Sex
 Females are more commonly affected than males.
 Age
- Most frequently seen in individuals between 40-60 years old.
 Work
- Sedentary workers are commonly affected than laborers.
 Diabetes
– people with diabetes are more likely to develop the condition and it also takes longer to
recover
 Immobility
– not moving a shoulder often enough after an injury can turn into a frozen shoulder Systemic
diseases such as tuberculosis, thyroid issues, Parkinson’s disease and cardiovascular disease puts
people more at risk.
III. Anatomy, Physiology, Kinesiology of Muscles

ANATOMY OF THE SHOULDR REGION:

A) Bones
 Scapula  is flat, triangular-shaped bone with three sides and three angles that sits
against the posterior thorax. B/n T2-T7. Composed of:
- Scapular spine
- Supraspinatus Fossa
- Infraspinatus fossa
- Acromion Process  lateral end of the spine of scapula: sits over the
GH jt
- Coracoid Process  anteriorly; sits blow the clavicle and is medial to
glenoid fossa; aka “ crow’s beak”

 Humerus  head and glenoid fossa form the GH jt

 Clavicle/ Collar bone / Dagger bone  keeps UE away from the body; mc fractured long
bone in the body; first and last to ossify
  Sternum/ Breast Bone/ Dagger Bone  has 3 parts: manubrium, body and xyphoid

B) Joints and Stabilizers

 Sternoclavicular Joint  only attachment of the UE to the trunk
- Interclavicular Ligament
- Costoclavicular Ligament
- Ant. and Post. Sternoclavicular Ligament

 Acromioclavicular Ligament  mc site of OA in the shoulder

- Coracoclavicular Ligament
- Acromioclavicular Ligament

- Glenohumeral Ligament
- Glenohumeral Ligament (Sup., Mid., Inf.)
- Coracohumeral Ligament

 Glenoid Labrum  fibrous ring that surrounds the rim of the glenoid fossa; its function
is to deepen the articular cavity.

 Rotator Cuff  the tendinous band formed by the blending together of the tendinous
insertions of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles :
These muscles help to keep the head of the humerus “rotating” against the glenoid
fossa during joint motion

C) Muscles of the Shoulder Joint

- Deltoid - Teres Minor
- Pectoralis major - Subscapularis
- Latissimus dorsi - Coracobrachialis
- Teres major - Biceps Brachii
- Supraspinatus - Triceps Brachii, Long head
- Infraspinatus

SCAPULOHUMERAL RHYTHM
• scapular rotation to facilitate shoulder movements (abduction & flexion)
– 1st 30 º of abduction or 45º of flexion -- scapula moves to a position of stability on
thorax
– beyond this initial range -- a 5:4 ratio of glenohumeral to scapular movements
– for total ROM have a 2:1 ratio (e.g. 180 º of abduction have 120 º of glenohumeral
mvmt and 60 º of scapular mvmt.

IV. Etiology
 The causes of frozen shoulder are not fully understood. There is no clear connection to arm
dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.
The causes for frozen shoulder could be:
a) Intrinsic, e.g. associated with shoulder disorder or trauma
(1) Stiffness following shoulder surgery
(2) Rotator cuff pathology
(3) Impingement syndrome
(4) Glenohumeral osteoarthritis
(5) Acromioclavicular joint osteoarthritis
(6) Posterior labral tears
(7) Biceps pathology
b) Extrinsic, e.g. associated with condition external to the shoulder
(1) Proximal humeral fracture
(2) Cervical spine disease
(3) Cardiac disease
(4) Neurological conditions
(5) Non-shoulder surgery
c) Systemic
(1) Diabetes mellitus
(2) Thyroid disease
 Primary: Here the exact cause is not known and it could be idiopathic.
 Secondary: According to Lumberg, the secondary causes could be:
- Shoulder causes: Problems directly related to shoulder joint which can give
rise to frozen shoulder are tendonitis of rotator cuff, bicipital tendinitis,
fractures and dislocations around the shoulder, etc.
- Nonshoulder causes: problems not related to shoulder joint like diabetes,
cardiovascular diseases with referred pain to the shoulder, which keeps the
joint immobile, reflex sympathetic dystrophy, frozen hand shoulder
syndrome, a complication of Colles fracture, can lead to frozen shoulder.
The reason could be prolonged immobilization of the shoulder joint due to
referred paun, et

V. Pathophysiology/Mechanism of Injury/Pathology
Primary
(Idiopathic):Unknown
v but associated
etiology,
with autoimmune
disorders (diabetes
mellitus, thyroid disease)
In select populations (age
40-60, women > men), the
glenohumeral joint capsule
ligaments become inflamed,
usually in one (non-
dominant) shoulder.
Over time, active shoulder
joint inflammation ↓ as
post-inflammatory healing
(i.e. local connective tissue
scarring) ↑.
Months later, active
shoulder joint
inflammation will stop, but
post-inflammatory tissue
healing creates abundant
scar tissue.
Years later, scar tissue in
the joint space and capsule
will eventually break down
itself, to be replaced by
healthy, flexible ligaments.
Pathophysiology
-
-
Secondary (Less Common):
Prolonged shoulder injury
(i.e. post shoulder surgery,
rotator cuff tear, humeral
head fracture).
Cytokinesis and other
inflammatory molecules
are released.
Less inflammatory molecules
are released in the shoulder.
Fibrotic scar tissue begin to
accumulate within the
glenohumeral at joint space.
No inflammatory molecules are
released.
More scar tissue accumulates in
the glenohumeral joint space,
as well as thickening and
contracting the joint capsule.
Joint space and joint capsule
mobility are gradually
restored.
Mechanism Signs/symptom/lab finding
Prolonged shoulder
immobility (i.e. after a stroke
that cause hemiplegia, or
during recovery after
breast/heart surgery).
Shoulder Pain: Diffuse
Triggers local 1st
throughout shoulder
nociceptors (pain stage:2-9
Severe, worse at night
receptor neurons). mos
Disabling (i.e. can’t
sleep on painful side.
Less activation of
local nociceptors. ↓Shoulder Pain
2nd stage:
↑ Shoulder stiffness 4-12 mos
Volume of space in the (progressive
joint capsule declines restriction of shoulder
movement).
No activation of local No shoulder pain
nociceptor.
3rd stage
Shoulder stiffness (↓ 5-24 mos
Severe ↓ in joint
active AND passive range
space and joint
of motion in shoulder,
capsule mobility.
any movement is mostly
scapulothoracic).
Shoulder range of
motion slowly returns Spontaneous
to normal (most of resolution, self-limited
disease
the time).
VI. Clinical Signs and Symptoms/ Physical Disabilities/ Impairments
 Acute Phase
- LOM (ER and ABD) due to pain and mm guarding
- Pain radiating below the elbow
- Tenderness @ below the edge of acromion
 Subacute Phase
- Capsular tightness begins
- Consistent with capsular pattern (most limited: ER and ABD) ( least limited: IR and
FLEXION)
- Pain at end range
 Chronic Phase
- Progressive restrictions of the GH jt
- Dec. jt play
- Inability to reach overhead, outward or behind the back
- Aching is usually localized to the deltoid region

FUNCTIONAL IMPAIRMENTS:
- Posture: possible faulty postural compensations with protracted and anteriorly
tilted scapula, rounded shoulders, and elevated and protected shoulder
- Decreased arm swing during gait
- General muscle weakness and poor endurance in the GH muscles leading to pain in
the trapezius, levator scapulae and posterior cervical muscles
- Substitution for limited GH motion with increased scapular motion, especially
elevation

COMMON ACTIVITY LIMITATIONS AND PARTICIPATION RESTRICTIONS:

- Inability to reach overhead, behind head, out to the side, and behind the back:
o Difficulty dressing
o Difficulty reaching hand into back pockets of the pants,
o Difficulty in self-grooming and bringing eating utensils to the mouth
- Difficulty lifting weighted objects
Limited ability to sustain repetitive activities

Symptoms :
- True shoulder pain
- Night pain of insidious onset
- Capsular Inflammation
- fibrous synovial adhesions
- Reduction of joint cavity
- Stiffness
Sign:
- Edema
- Muscle atrophy
 - Tenderness
- Painful restriction of active and passive motion
- Passive elevation less than 100ᵒ
- Passive lateral rotation less than 30ᵒ
- Passive medial rotation less than reaching he level of L5.
- All other shoulder conditions excluded

VII. Diagnostic Tools/ Procedures or Test

Special test:

 Speed’s test
 Position:
- sitting with elbow at 90ᵒ flexion and slight ER, elbow extension and
forearm supination
 Stimulus :
- apply downward resistance into shoulder extension
 (+)response:
- localized pain over biceps tedon origin
 Hawkin’s kennedy impingement test
 Position:
- sitting
 Stimulus:
- passive flexion to 90ᵒ and IR of the arm with the elbow flexion;
- Stabilized elbow and push down on the wrist into more IR.
 (+)response:
- pain in the area of supraspinatus tendon/ coracoacromial ligament
 Drop arm (codman’s test)
 Position:
- sitting/standing
 Stimulus:
- examiner abducts arm to 90ᵒ and pt. drops the arm slowly
 (+)response:
- inability to return arm slowly or has severe pain
 Neer impingement test
 Position:
- Sitting
 Stimulus:
- Pt.’s arm is forcibly elevated thru forward flexion by examiner causing
jamming of the greater tuberosity against the inferior border of the
acromion.
 (+)response:
- Pain shows on pt.’s face
 Supraspinatus (empty can )test
 Position
- Sitting
 Stimulus:
- Pt.’s soulder abducted to 90ᵒ with neutral rotation, examiner resist
 - Shoulder is then IR(thumbs down) and angled forward 30ᵒ(empty can
position) as resistance is given again.
 (+)response:
- Weakness and pain
 Apley’s scratch test
 Position
- Sitting or standing
 Stimulus:
- Passive adduction, approximating elbow to opposite shoulder
 (+)response:
- Pain at AC jt,.
Diagnostic tools:

 Arthrogram depicts presence of adhesive capsulitis

 Plain x-rays should be done to rule out concomitant pathology such as subluxation or
tumor.
 Dynamic sonography may be useful to specifically identify the movements most
affected and rule out other pathology.
 Laboratory tests should be considered to rule out systemic diseases.

VIII. Differential Diagnosis Conditions

Rotator Cuff Frozen Shoulder Atraumatic Cervical

Lessions Instability Spondylosis

History - Age 30-50 years - Age 45+ - Age 10-35 - Age 50+ years
- Pain and - Insidious years - Acute or
weakness after onset or after - Pain and chronic
eccentric load trauma or instability with
surgery activity
- Functional - No history of
restriction of trauma
lateral
rotation,
abduction,
and medial
rotation
Observation - Normal bone - Normal bone - Normal bone - Minimal or no
and soft tissue and soft tissue and soft tissue cervical spine
outlines outlines outlines movement
- Protective - Torticollis may
shoulder hike be present
may be seen
Active movement - Weakness of - Restricted - Full or - Limited ROM
abduction or ROM excessive ROM with pain
rotation, or - Shoulder
both hiking`
- Crepitus may
be present
Passive - Pain f - Limited ROM, - Normal or - Limited ROM
movement impingement especially in excessive ROM
occurs lateral,
rotation,
abduction,
and medial
rotation
(capsular
pattern)
Resisted - Pain and - Normal, when - Normal - Normal except
isometric weakness on arm by side if nerve root
movement abduction and compressed
lateral rotation - Myotome may
be affected

Special test - Drop-arm test - None - Load and shift - Spurlin’s test
positive test positive positive
- Empty can - Apprehension - Distraction
positive test positive test positive
- Relocation test - ULTT positive
positive - Shoulder
- Augmentation abduction test
test positive positive

Sensory function - Not affected - Not affected - - Dermatomes

and reflexes affected
- Reflexes
affected

Palpation - Tender over - Not painful - Anterior or - Tender over

rotator cuff unless capsule posterior pain appropriate
is stretched vertebra or
facet

Diagnostic - Radiography: - Radiography: - Negative - Radiography:

imaging upward negative narrowing
displacement - Anthrography: osteophytes
of humeral decreased
head; acromial capsular size
spurring
 - MRI diagnostic

IX. Managements

 Pharmacological Management
 Non-steroidal anti- inflammatory drugs:
- Aspirin and ibuprofen to reduce pain and swelling
 Steroid injections:
- Cortisone is a powerful anti-inflammatory medicine that injected directly into
the shoulder joint.

 Medical and Surgical Management

 Manipulation under anesthesia
- which may be done in combination with steroid injection, distension
arthrography, or arthroscopy.
- Contraindications to closed manipulation under anesthesia include anti-
coagulation or bleeding diatheses, significant osteopenia, or recent surgical
repair of shoulder soft tissue, fracture or neurological lesion. Complications may
include humeral fracture, dislocation, cuff injuries, labral tears or brachial plexus
injury.
 Arthroscopic capsular release or open surgical release
- may be appropriate in rare cases with failure of previous methods and when the
patient has demonstrated ability to follow through with required physical and
occupational therapy. Other disorders, such as impingement syndrome, may
also be treated at the same time. Radiofrequency is not recommended due to
reported complications from chondrolyis.
 Physiotherapeutic management
Heat modalities
Heat
- prior to exercise for pain relief, to promote relaxation and to increase tissue
extensibility
Ice/cold packs following exercises
- to reduce pain and inflammation
Ultrasound
- is the application of heat through sound waves to deep tissue of the body. It is used to
reduce pain, relax tight muscles and reduce muscle spasm.
 - Ultrasound is shown to have an analgesic effect from the vasodilatation that it causes,
which may help remove the byproducts of the injured tissue, that often stimulates the
pain fibers.
- Ultrasound is also shown to relieve muscle spasms by decreasing receptor activity and
sensitivity to stretching
Transcutaneous electric stimulation (TENS):
- TENS has been shown to significantly increase range of motion more than heat.
- There are two theories of why TENS is effective in pain relief:
- The first theory “the gate control theory of pain” states that if the fibers
transmitting touch and proprioception sensations are over stimulated, they
may “flood” the pathways to the brain, preventing the pain signals from
reaching the brain.
- The second theory postulates that “the electrical stimulation of nerve fibers
causes the release of body’s own “natural opiates”, thereby decreasing pain.
- The pain relief is directly proportional to the TENS parameters of frequency and
amplitude. As both frequency and amplitude increase, pain relief also increases
Soft tissue mobilization (STM):
- Soft tissue mobilization and deep friction massage may have benefits in the treatment
of SAC.
- Deep friction massage using the Cyriax Method is shown to be superior to superficial
heat and diathermy treatment of SAC.
- Utilizing the Cyriax method, STM directed at the specific limitation of the periarticular
structures in combination with a simple home exercise program appeared to be an
effective treatment in patients with SAC stage II, as measured by improved ROM of the
subjects
Therapeutic exercises:
- Most commonly used exercises for patients with SAC are active-assistive range of
motion (AAROM) exercises and passive ROM.
- Pt uses the uninvolved arm, or equipment such as the rope and pulley, wand/ T bar or
exercise balls. Generally, these exercises are performed for flexion, abduction and
external and internal rotation range of motions. Improved in pain, ROM, and shoulder
function.
Resistive exercises
- typically include strengthening of the scapular stabilizers, rotator cuff, and lower
trapezium muscles.
- As the range of motion improves, shoulder strengthening is appropriate intervention as
long as the therapist stimulates normal movement pattern without substitution of
scapular movements over GHJ mobility.
Proprioceptive neuromuscular facilitation (PNF):
- PNF is the application of specific stimuli to elicit and improve motor activity
Hold-relax and contract-relax techniques
 - are used frequently in the management of SAC.
- During this technique, the patient will relax the antagonist muscles, and then the
physical therapist will move the limb through the available range to the point that soft
tissue limitation is felt to gain further ROM.
End range isometric exercises
- are used for anterior deltoid muscles in the end range of forward flexion in supine after
passive stretch to train the deltoid muscles to contract isometrically for 3-5 seconds.
- The patient can improve strength in the gained range during therapy sessions and
maintain this range of motion.
- These techniques, when used effectively, can improve the patient outcome.
Home program
- designed in the first treatment session by the physical therapist is individualized and
patient specific. Includes, self ROM and strengthening exercises for rotator cuff and
scapular stabilization
Range of Motion and Stretching Exercises
Pendulum Exercise Bend over at the waist so that the arm falls away from the body and dangles in a
relaxed way. Use your body to initiate a circularmotion. Make small circles while keeping the shoulder
relaxed Do this for 2 to 3 minutes at a time.
Table-top Arm Slides Sit in a chair adjacent to a smooth table top Lift the involved arm with the
uninvolved arm and place the hand and forearm on the table. Bend forward at the waist allowing the
hand and arm to slide forward. Do 10 repetitions.
Supine Neutral External Rotation Lie on your back. Keep the arm and elbow tight against your side.
Keep the elbow at a 90 degree angle. Push the stick into the hand of the involved arm to make the arm
rotte away from the body. Do 10
Supine Passive Forward Flexion Lie on your back. Using a stick (figure A.), or using the strength of the
uninvolved arm
Wall Climb Stretch Stand facing a wall, place the hand of the affected arm on the wall. Slide the hand up
the wall, allowing the hand and arm to go upward. As you are able to stretch the hand and arm higher,
you should move your body closer to the wall. Hold the stretch for 15to 20 seconds. Do 10 repetitions.
Internal Rotation: Behind-the-Back Stretch Sitting in a chair or standing, place the hand of the affected
arm behind your back at the waistline. Use your opposite hand to help the other hand higher toward the
shoulder blade of the opposite shoulder. Do 10 repetitions.
Supine External Rotation with Abduction Lie on your back. Place your hands behind vour head as shown
in the top illustration. Slowly lower your elbows to stretch the shoulders toward the surface you are
lying on. Do 10 repetitions.
Horizontal Adduction Stretch Lying on your back, hold the elbow of the affected arm with your opposite
hand. Gently stretch the, elbow toward the opposite shoulder. Later, this stretch can be done standing.
Do 10 repetitions.
Standing Neutral External Rotation Hold a door handle or frame with the hand of the involved arm.
While keeping the involved arm firmly against your side and the elbow at a right (90 degree) angle,
Rotate your body away from the door to produce outward rotation at the shoulder. Do 10 repetitions.
External Rotation in Corner Standing facing a comer, position the arms as illustrated with the elbows at
shoulder level. Lean your body gently forward toward the comer until a stretch Is felt. Hold this position
gently for15 to 20 seconds. Repeat 10 times
.Internal Rotation Stretch Standing facing a comer, position the arms as illustrated with the elbows at
shoulder level. The throwing arm is the one with the hand pointed down. Lean your body gently forward
toward a comer until a stretch is felt Hold this position gently for 15 to 20 seconds. Repeat 10 times.
Shoulder Shrugs and Scapular Retraction Shrug shoulders upward as illustrated in figure 1. Pinch
shoulder blades backward and together.

SPECIFIC TREATMENT TECHNIQUES BASED ON ADHESIVE CAPSULITIS STAGES

Stage 1: Painful Inflammatory Stage
 Moist hot packs
 AAROM with L bar
 Pendulum exercise
 Single-plane mobilization
 Soft tissue mobilization
 Postural exercise, stretching, corrections
 Stretching technique (physiologic, CR,HR)
 Midrange submaximal isometrics
 Home program (10-12 times daily)
 Motion frequently during the day
 Light motion
Stage 2: Acute Adhesion with Synovitis Stage
 Active warm-up
 AAROM exercise
 Single-plane, end-range mobilization
 Stretching technique (physiologic, CR,HR)
 End-range stretching
 End-range submaximal isometrics
 Self-capsular stretching
 Home program (8-10 times daily)
 Frequent stretching and ROM exercise
 Sustained stretch at end range
Stage 3: Maturation Adhesion Stage

 Heat
 Active warm-up (AAROM,UBE)
 LLLD stretch with concomitant superficial heat
  Aggressive joint mobilization
 Single multi-planar glides and combined glides
 Joint mobilization- emphasize inferior glides
 CR,HR stretching
 Self- joint mobilization at home
 Sustained stretching at home (TERT principle)
 Strengthening (PNF)exercises
 Home program (4-6 times daily)
- Keep it moving
Stage 4: Chronic Adhesion Stage
 Continue all tratments listed
 Durng this phase, emphasize
 Oblique and mulitplanae mobilizations
 Sustained LLLD stretching
 Use of home LLLD device for 15-min sessions (4 times daily)
 Inferior mobilizations
 Postural exercises and stretching
Note: AAROM active resisted range of motion; CR contract relax; HR hold relax; LLLD low load long
duration; PNF proprioceptive neuromuscular fasciculation; TERT total end range time; UBE upper body
ergometer

XII. REFFERENCES

 Physical Medicine and Rehabilitation 1st Edition by: Randall L. Braddom, M.D, M.S
 Rehabilitation Medicine Principles and Practice 2nd Edition by: Joel A. DeLisa and Bruce M. Gans
 Brunnstom’s clinical kinesiology 5th edition
 Brunnstom’s clinical kinesiology 6th edition
 Handbook Of Orthopedic Surgery 10th Edition By Brashear

 Pathology and Intervention in Musculoskeletal Rehabilitation By David J. Magee, James E.

Zachazewski, William S. Quillen, Robert C. Manske
 Operative Arthroscopy edited by John B. McGinty, Stephen S. Burkhart
 The Athlete's Shoulder By Kevin E. Wilk, Michael M. Reinold, James Rheuben Andrews