Keywords: Adhesive Capsulitis, Pathology, Passive ROM, Joint Capsule, Physiotherapy, Special tests, Differential Diagnosis, Capsular Release.
This information has been displayed with the kind permission of Lennard Funk and SportsInjuryClinic. Parts of the pages have been copied from Shoulderdoc.co.uk and SportsInjuryClinic.net.
Clinically Relevant Anatomy
Normal Shoulder Capsule: The lining of the shoulder joint, known as the ‘capsule’, is normally a very flexible elastic structure. It’s looseness and elasticity allows the huge range of motion that the shoulder has. With a frozen shoulder this capsule (and its ligaments) becomes inflamed, swollen, red and contracted. The normal elasticity is lost and pain and stiffness set in.
Frozen Shoulder Capsule:
Frozen shoulder, as seen at arthroscopy (note the very swollen and reddened inflamed capsule – it is not surprising that this is such a painful problem!):
Adhesive capsulitis (Frozen Shoulder) is an extremely painful condition in which the shoulder is completely or partially unmovable (stiff). It is one of the most painful conditions of the shoulder (the others being Calcific Tendonitis or referred Nerve pain from the neck).
- Frozen shoulder often starts out of the blue, but may be triggered by a mild injury to the shoulder. The condition usually goes through three phases, starting with pain, then stiffness and finally a stage of resolution as the pain eases and most of the movement returns. This process may take a long time, sometimes as long as two or more years.
- Frozen shoulder may be associated with diabetes, high cholestrol, heart disease and is also seen in patients with scar tissue in their hands, a condition called Dupuytrens contracture. It may follow an injury to the shoulder or surgery.
- Thickening of the joint capsule, adhesions, and decreased joint volume leading to painful stiffness and loss of motion are the pathologic hallmarks (Martin, 2008).
Three stages of development:
Typical Primary frozen shoulder develops slowly, and in three phases:
- Freezing phase: Pain increases with movement and is often worse at night. There is a progressive loss of motion with increasing pain. This stage lasts approximately 2 to 9 months.
- Frozen phase: Pain begins to diminish, however, the range of motion is now much more limited, as much as 50 percent less than in the other arm. This stage may last 4 to 12 months.
- Thawing phase: The condition may begin to resolve. Most patients experience a gradual restoration of motion over the next 12 to 42 months
- Spontaneous onset of symptoms.
- Loss of PROM and AROM
- Limited Abduction followed by ER.
- Pain of shoulder and into upper arm.
- Rotator Cuff Tear
- Slap lesion
- Sub-acromial Impingement
- Poor scapulohumeral rhythm
- C6 neural compression
- Shoulder Objectives measures: Wright and Bauggarten (2012)
- Flexi-level Scale of Shoulder Function
- Shoulder Disability Questionnaire – Netherlands
- Shoulder Disability Questionnaire – UK
- Shoulder Pain and Disability Index
- Shoulder Rating Questionnaire (Scroll down to appendix 2 to view)
- American Shoulder and Elbow Surgeons’ patient self-evaluation form
- Measuring the range of passive external rotation reliably is difficult, and this should be recognised. (Hanchard et al, 2011) suggest a method in standing which involves estimating range to the nearest 30°. (Where an estimate falls between two values, the smaller can be taken.)
General Advice for a patient:
- If nothing is done most frozen shoulders improve significantly over 2-4 years after onset. However the pain and limitations of the stiff shoulder generally require treatment. The treatment required depends on the severity of the pain and stiffness. Education on the nature of the disease is important so that the patient has a clear understand of the phases and treatments based accordingly.
- Self limiting condition
- Patients may need to modify activities at work, home or with recreational activities.
- As a physiotherapist you will need to provide task techniques that avoid aggravating the pain. Placing the affected arm into an arm hole first will require less stress through the joint.
- It is important to keep the arm supported with sustained positions. To reduce pain you may suggest “hugging a pillow”, avoid lying on the affected shoulder.
- Wearing loose clothing/ front opening (ie blouse/shirt).
- Pacing activities will help minimise pain
- Remember: As a physio you are trying to improve quality of life (QOL). Try to formulate a plan where the patient can still complete every day activities/hobbies if possible.
- Education on the pain mechanisms involved are important to help the patient self managment and understand principles of physio.
Health professional and Physiotherapy management.
Clinical Guidelines Overview:
- Manage appropriately to the phase and thus pain mechanism involved.
- Increase flexibility of the tissues to increase ROM.
- Reduce Pain.
- Improve muscle balance around the shoulder.
These must be appropriate to the phase and thus pain mechanism involved.
- Soft tissue mobilisations
- Manual therapy
- Muscle Energy techniques
- Strengthening exercises.
- Shoulder Distraction
- Advice and activity modification
- Pendular exercises
- Medication ( NSAID’s and Opoids)
- Corticosteriod Injection
- If conservative measures fail the a capsular release or manipulation under anaesthetic (MUA) can be performed.
Medical and Surgical Management
- Injections – reduce inflammation and provide pain relief.
- Hydrodilatation Procedure – more effective than simple injections in relieving severe pain and improving range of motion.
- Surgery – Surgery has been shown to be of benefit in both the early and later stages of a Frozen Shoulder. This may involve an arthroscopic
- Capsular Release or Manipulation Under Anaesthetic (MUA). We prefer the Capsular Release procedure. It is excellent for both pain relief and restoring movement, with a success rate of 96% at 6 months. Intensive physiotherapy is essential after the surgery.
Evidence Based Clinical Guidelines
Sure you know this inside out? Could you explain it to a patient/ formulate a problem list and provide appropriate management? Complete the quiz to check.
Hanchard N, Goodchild L, Thompson J, O’Brien T, Richardson C, Davison D, Watson H, Wragg M, Mtopo S, Scott M. (2011) Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder v.1.6, ‘standard’ physiotherapy. Endorsed by the Chartered Society of Physiotherapy.