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Tony Kottoor, Kameron Wallis, Lauren Geer, Danielle Goettl

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1 Tony Kottoor, Kameron Wallis, Lauren Geer, Danielle Goettl
Adhesive Capsulitis Tony Kottoor, Kameron Wallis, Lauren Geer, Danielle Goettl CPG:

2 Review of Shoulder Anatomy
3 Bones 3 Joints 1 Articulation Talk about everything in detail: mention all the ligaments, bursae, etc.

3 Normal ROM of Shoulder Abduction: 180 Adduction: 45 Flexion: 180
Extension: 50-60 Internal Rotation: 70 External Rotation: 90 Horizontal Abduction: 45

4 Definition and Etiology
Adhesive capsulitis is characterized by spontaneous shoulder pain with progressive fibrosis and inflammation, ultimately leading to a capsular contracture of the glenohumeral joint. 2,4 The cause remains unclear. 4 More females are affected than males, and is most commonly seen in ages ,4 Adhesive capsulitis will commonly affect the non-dominant hand. 4 Development of adhesive capsulitis has been associated with diabetes mellitus, thyroid dysfunction, autoimmune disorder, Dupuytren's contractures, treatment of breast cancer, CVA or MI,2,4 as well as those with sedentary vocations are at an increased risk. 4 Stages: T

5 Stages Stage 1: The pre-adhesive stage 1
Lasts 0-3 months, hypervascular synovitis, normal capsule Patients present with mild or no end-range limitations and pain Treatment goals are to decrease pain by interrupting the inflammation pain cycle Stage 2: Acute Adhesive or Freezing Stage 1 Lasts 3-9 months, early adhesion formation leading to capsular contraction and thickening Patients present with high level of discomfort, limited PROM /AROM, increased pain near end-range. Treatment goals: restore the normal glenohumeral biomechanics, decreasing inflammation and pain. T

6 Stages Cont. Stage 3: Fibrotic or Frozen Stage 1
Lasts 9-15 months, mature adhesion in the capsule and axillary fold. Patients present with significant motion limitations but minimal pain. Treatment goals are to aggressively treat and restore normal range of motion function of the joint. Stage 4: Thawing Stage 1 Lasts months, Severe capsular restriction without apparent synovitis Patients present with painless restriction of motion, which typically improves by remodeling. Treatment goals are to maintain normal ROM, function, and GH biomechanics & avoiding pain and inflammation.

7 Meet Rey Ryanolds! A 30-year-old male business project manager
He reports constant, mild, dull generalized left shoulder pain that was precipitated by clicking and followed by a gradual loss of motion Initially, more pain, but then tapered off Postural evaluation: elevation of the left shoulder Functional Limitations include: inability to wash and comb his hair inability to retrieve his wallet from his back pocket now performs these with right shoulder Anti-inflammatory medications and rest provided no relief He began recreational weightlifting approximately one year prior to the onset of his symptoms, noted that overhead movements and lateral dumbbell raises increased his pain so he discontinued these exercises

8 Case Study Info Imaging: radiograph of left shoulder was negative for fracture or dislocation. Active trigger-points palpable in the left trapezius, deltoid and teres muscles. The patient tested negatively for cervical compression and thoracic outlet syndrome. PROM and AROM were moderately decreased, with minimal pain in the end ranges. Goniometric measurements: Flexion: 20/45 Extension: 20/45 Abduction: 120/180 Internal rotation: 20/55 External rotation: 10/45 My goal is to be able to return to my sword play!!

9 Case Study Info Rationale for this case study: Very realistic to a “typical” patient we might see. Patient is also past the Pre-adhesion stage (stage 1), due to “tapering off of pain” places patient in fibrotic stage (stage 3). “...patients in stage 2/stage 3 were found to better respond to physical therapy, stretching, and other rehabilitation programs as compared to patients in stage 1” Jain 2014 Most relevant impairments and limitations: Pain Decreased AROM & PROM Inability to perform ADL’s Shoulder weakness Postural deviation in shoulder D

10 Specific Interventions
Stages 1 - 2: Reducing pain and maintain ROM Corticosteroid injections Use of cryotherapy and ischemic compression of palpable trigger points around the shoulder MT and other modalities (US, Estim, heat, LLLT etc.) for further pain reduction Light mobilization of scapula and T-spine Passive ROM of shoulder joint followed with light stretching in planes of motion w/ emphasis on capsular pattern in the available ROM detail.aspx?cid= fa0-4fc0-ba17- ea32751d7412 PROM, AROM, AAROM exercises (pendulum swings) TENS for pain relief Strengthening exercises within pain free ROM Joint mobilization: grades I-II used in the early stages to inhibit pain and to improve joint nutrition, grades III-IV to increase tissue extensibility Moist heat Stretching Muscle re-education to gain normal GH joint and ST biomechanics Intra-articular corticosteroid injections More effective if used in combination with stretching and mobility exercises (4-6 weeks) Stretching exercises Patient education Help patient to understand natural course of disease Instruct exercises within pain free ROM (pendulum exercises) Active stretching techniques within pain free ROM Modalities (US, shortwave diathermy, Estim) More effective if used in combination with stretching and mobility exercises GH joint manipulation GH transitional manipulation (if not responding to conservative Tx)

11 Specific Interventions Cont.
Stage 3: Improve ROM and strength PNF stretching patterns (contract-relax and dynamic reversals) High grade shoulder mobilization (post. Glide > ant. glide) Trigger point release (subscap., Lat. dorsi, teres, etc.) STM: Deep cross friction/IASTM around shoulder joint muscles Strengthening exercises Resisted IR/ER Unweighted → weighted pendulum Finger walking within pain free ROM Stage 4: Return of normal shoulder body mechanics Continuation of Stage 3 parameters if needed Neuromuscular re-education (using visual and biophysical feedback) Continuation of HEP

12 HEP - Focus on ROM and strength
Initial HEP: Maintain ROM Self administered heat for reduction of pain/spasm Light stretching exercises within pain free ROM (as tolerated) Body assisted unweighted pendulum swings IR w/ towel + ER against doorway Cross body pull AA flexion in supine + armpit/squat stretch Pectoralis stretching w/ tandem towel HEP progression: Improve ROM and increase strength Finger walking to end range + stretch at end range → 3x5 reps Weighted pendulum swings (CW, CCW, 8) → each direction x10 IR/ER against structure → dynamic w/ resistive band → 10-15x Resisted flexion/extension Vertical lifts → unweighted to weighted → 15x Stretching and strengthening (can use heat before exercise to increase mobility and reduce pain) Pendulum swings, IR w/ towel Crossbody pull Finger walk Armpit/squat stretch Forward flexion (supine) IR and ER against structure or resistance band

13 Take Home Points Phase dictates most appropriate intervention: different treatments will be more effective at different times. Ex: Corticosteroid injections are recommended for Stage 1 Frozen Shoulder, while Corticosteroid injection along with PTI is advised in Stage 2 patients.2 Desired outcome (improvement in pain, ROM, function) should guide which intervention is selected. Ex: Low - level laser therapy is strongly suggested for pain relief and moderately suggested for improving function but not recommended for improving ROM. 2 More research is necessary to solve this pathology! Gaps in treatment methods Idiopathic Cause You Can Help! Go Be Proactive and get involved with research!

14 References Flynn, M. (2005). Adhesive Capsulitis: A Case Study. Dynamic Chiropractic. 23 (2), Jain T.K. & Sharma N.K. (2014). The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: A systematic review. Journal of Back and Musculoskeletal Rehabilitation, 27, Kelley, M. Shoulder Pain and Mobility Deficits: Adhesive Capsulitis. J Orthop Sports Phys Ther 2013;43(5):A1-A31. doi: /jospt Neviaser, A. S., & Hannafin, J. A. (2010). Adhesive Capsulitis A Review of Current Treatment. The American journal of sports medicine, 38(11),


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