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
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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),