Conditions & Treatments - Adhesive Capsulitis - Frozen Shoulder

Adhesive capsulitis, commonly termed "frozen shoulder," is a complicated, painful condition in which a patient presents with shoulder pain and develops a gradual loss of both active and passive shoulder range of motion (1). Adhesive capsulitis occurs in approximately 2-5% of the population and is more prevalent in females, individuals age 40-65, and those who have had a prior episode of adhesive capsulitis in the opposite shoulder (1). Two types of adhesive capsulitis exist: primary idiopathic adhesive capsulitis and secondary adhesive capsulitis. Secondary adhesive capsulitis may be related to systemic disease (diabetes mellitus and thyroid disorders) or a variety of intrinsic or extrinsic factors (stroke, proximal humeral fracture, causative rotator cuff, and labral pathology) (2). Pathology/Etiology (3) In patients with adhesive capsulitis, the inferior capsule of the glenohumeral joint thickens (a thickening observed on an MRI of >4 mm is considered diagnostic of the condition) Arthrograms reveal reduced glenohumeral joint spaces (10-15 mL, normal is 20-30 mL). Serum cytokine, which facilitates tissue repair and remodeling as part of the inflammatory process of healing, is often elevated. Some researchers believe that a minor injury triggers the healing process, and fibroblasts produce more collagen than is reabsorbed, leading to excess collagen and stiffness in the joint capsule. Staging Several stages are often used to describe the progression of adhesive capsulitis. A description of each stage can be found in the table below. Table1: Stages of Adhesive Capsulitis (3) Stage Stage I Stage II Stage III Stage IV Nickname Pre-freezing Freezing Frozen Thawing Duration 0-3 months 3-9 months 9-14 months > 14 months Presentation Pain with AROM/PROM; pain inhibition Chronic pain with AROM/PROM; spasm end-feel, may have night pain, positive impingement signs Decreased pain, globally limited ROM, pain at end range Stiffness, minimal pain, slow recovery of ROM Pathology Hypertrophic vascular synovitis noted from arthroscopy; normal capsule as indicated by biopsy Dense hypervascular synovitis Capsule shows dense scar formation Patient is improving

Research since the creation of the Clinical Practice Guidelines has continued to support the inclusion of static stretching in the treatment of adhesive capsulitis.  In a study by Ibrahim et al. (4), sixty patients with adhesive capsulitis were randomly assigned to a treatment group or a control group.  Both groups received 3 PT sessions/wk for 4 weeks; however, the treatment group also used a static progressive stretch device (one 30 minute session per day for the first week, two 30 minute sessions per day for the second and third weeks, and three sessions per day for the fourth week).  At baseline, no differences existed between the two groups.  However, after the intervention, differences between the two groups were statistically significant.  The treatment group had lower pain ratings, lower DASH scores, increased PROM shoulder abduction, increased PROM shoulder ER, and increased AROM shoulder abduction.  The differences between the two groups persisted at a 12 month follow up (4).

Outcomes

Although mild to moderate mobility deficits and pain may persist 12-18 months after the onset of adhesive capsulitis, many patients report minimal to no disability (2).  27-50% of patients report having mild symptoms 2-7 years after the onset of adhesive capsulitis (3).  It is important to note that patients with diabetes mellitus may experience worse outcomes (2).

Last revised: July 20, 2014
by Michelle Kornder, DPT

References

1) Lynch TS and Edwards SL. Adhesive capsulitis: current concepts in diagnosis and treatment. Current Orthopaedic Practice. 2013;24(4):365-369. Available from University of Wisconsin Madison, Madison, WI. Accessed July 7, 2014.
2) Kelley MJ, Shaffer MA, Kuhn JE et al. Shoulder Pain and Mobility Deficits: Adhesive Capsulitis. J Orthop Sports Phys Ther. 2013;43(5):A1-A31. Available from University of Wisconsin Madison, Madison, WI. Accessed July 7, 2014.
3) Hallisy, Thein-Nissenbaum. PT 677 -MS Dysfunction: Examination, Diagnosis, & Management II. Madison, WI: Department of Physical Therapy; 2013.
4) Ibrahim M, Donatelli R, Hellman M, Echternach J. Efficacy of a static progressive stretch device as an adjunct to physical therapy in treating adhesive capsulitis of the shoulder: a prospective, randomised study [published online ahead of print 2013]. Physiotherapy. Available from University of Wisconsin Madison, Madison, WI. Accessed July 7, 2014.
5) Frozen Shoulder-OrthoInfo-AAOS. American Academy of Orthopaedic Surgeons. Updated January, 2011. http://orthoinfo.aaos.org/topic.cfm?topic=a00071. Accessed July 7, 2014.
6) Standard of Care: Shoulder Adhesive Capsulitis. Brigham and Women's Hospital. Updated 2010. http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/physical%20therapy%20standards%20of%20care%20and%20protocols/shoulder%20-%20adhesive%20capsulitis.pdf. Accessed July 7, 2014.
7) Physical Therapist's Guide to Frozen Shoulder (Adhesive Capsulitis). American Physical Therapy Association Move Forward Guide. http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=00661806-1fa0-4fc0-ba17-ea32751d7412#.U7sFD_ldVBY. Accessed July 7, 2014.