1. [ CLINICAL COMMENTARY ]
MARTIN J. KELLEY, PT, DPT, OCS¹ PT, PhD² PT, DPT, OCS³
Frozen Shoulder: Evidence and a Proposed
Model Guiding Rehabilitation
F
rozen shoulder, or adhesive capsulitis, describes the common history, clinical presentation, and recov-
shoulder condition characterized by painful and limited active ery. Codman22 described frozen shoulder
as “a condition difficult to define, difficult
and passive range of motion (ROM). Frozen shoulder is reported
to treat, and difficult to explain from the
to affect 2% to 5% of the general population,4,13,64,88 increasing point of view of pathology.” Nevaiser80
to 10% to 38% in patients with diabetes and thyroid disease.4,5,13,64,71,88 introduced the term adhesive capsulitis
Individuals with primary frozen shoulder are commonly between 40 to describe the inflamed and fibrotic con-
and 65 years old,79,82,83 and the incidence appears higher in females dition of the capsuloligamentous tissue.
than males.4,9,43,64,71,109 The occurrence of frozen shoulder in 1 shoulder The term frozen shoulder will be used,
because it encompasses both primary
increases the risk of contralateral shoulder involvement by 5% to
frozen shoulder (adhesive capsulitis) and
34%, and simultaneous bilateral shoul- To date, the etiology of frozen shoul- secondary frozen shoulder related to sys-
der involvement occurs as often as 14% der remains unclear; however, patients temic disease and extrinsic or intrinsic
of the time.16,39,64,107 typically demonstrate a characteristic factors, excluding cerebral vascular ac-
cident, proximal humeral fracture, and
Frozen shoulder or adhesive cap- evidence that glenohumeral intra-articular corti- causative rotator cuff or labral pathol-
sulitis describes the common shoulder condition costeroid injections have a significantly greater ogy. This paper will present an overview
characterized by painful and limited active and 4- to 6-week beneficial effect compared to other of the classification, etiology, pathology,
passive range of motion. The etiology of frozen forms of treatment. A rehabilitation model based examination, and plan of care for frozen
shoulder remains unclear; however, patients on evidence and intervention strategies matched shoulder.
typically demonstrate a characteristic history, with irritability levels is proposed. Exercise and
clinical presentation, and recovery. A classifica- manual techniques are progressed as the patient’s
tion schema is described, in which primary frozen
irritability reduces. Response to treatment is based
shoulder and idiopathic adhesive capsulitis are
T
on significant pain relief, improved satisfaction, he absence of standardized
considered identical and not associated with a
and return of functional motion. Patients who
systemic condition or history of injury. Secondary nomenclature for frozen shoulder
do not respond or worsen should be referred
frozen shoulder is defined by 3 subcategories: causes confusion in the literature.
systemic, extrinsic, and intrinsic. We also propose for an intra-articular corticosteroid injection.
Patients who have recalcitrant symptoms and
Lundberg64 first described a classification
another classification system based on the
disabling pain may respond to either standard or system identifying primary frozen shoul-
patient’s irritability level (low, moderate, and high),
that we believe is helpful when making clinical translational manipulation under anesthesia or der as idiopathic and secondary frozen
decisions regarding rehabilitation intervention. arthroscopic release. shoulder as posttraumatic. Nash and Ha-
Nonoperative interventions include patient educa- Level 5. J Orthop Sports
zelman77 expanded the classification sys-
tion, modalities, stretching exercises, joint mobili- tem by including diseases such as diabetes
Phys Ther 2009; 39(2):135-148. doi: 10.2519/
zation, and corticosteroid injections. Glenohumeral mellitus, myocardial infarction, or vari-
jospt.2009.2916
intra-articular corticosteroid injections, exercise,
ous neurologic disorders under secondary
and joint mobilization all result in improved short- adhesive capsulitis, corticoster-
and long-term outcomes. However, there is strong oid injection, glenohumeral joint, joint mobilization
frozen shoulder. Zuckerman128 proposed
a classification schema where primary
1
Musculoskeletal Team Leader, Good Shepherd Penn Partners, Philadelphia, PA. 2 Professor, Arcadia University, Glenside, PA. 3Advanced Clinician II, Good Shepherd Penn
Partners, Philadelphia, PA. Address correspondence to Dr Martin J. Kelley, Good Shepherd Penn Partners, Penn-Presbyterian Medical Center, 39th and Market Sts, Philadelphia,
PA 19104.
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 135

2. [ CLINICAL COMMENTARY ]
determined based on pain, range of mo-
Frozen Shoulder tion (ROM), and extent of disability. Pa-
tients with low irritability have less pain
and have capsular end feels with little or
no pain; therefore, active and passive mo-
Primary (idiopathic) Secondary (known tion are equal and disability lower. These
disorders)
patients typically report stiffness rather
than pain as a chief complaint. Patients
with high irritability have significant pain
resulting in limited passive motion (due
Systemic: Extrinsic: Intrinsic:
to muscle guarding) and greater disabil-
y
m disease s ity. These patients typically report pain
m c rather than stiffness as a chief complaint.
m A s While these criteria are not time based,
s most commonly, patients in early-stage
frozen shoulder have a high level of irri-
tability, while patients in later stages have
low irritability.
Classification system. Reprinted with permission from Coumo F. Diagnosis, classification, and
management of the stiff shoulder. In Iannotti JP, Williams GR, eds. Disorders of the Shoulder: Diagnosis and
Management. Philadelphia, PA: Lippincott, Williams & Wilkins; 1999.
T
he benefit of Zuckerman’s clas-
sification system is that it organizes
Irritability Classification the following previously described
possible etiologies of frozen shoulder into
subcategories: rotator cuff contracture,69
biceps tenosynovitis,27 subscapularis trig-
High pain ( 7/10) Moderate pain (4-6/10) Low pain ( 3/10)
ger points,31,113 autoimmune response,16,17
Consistent night or resting pain Intermittent night or resting pain No resting or night pain
and autonomic reflex dysfunction.100
High disability on DASH, ASES, PSS Moderate disability on DASH, ASES, PSS Low disability on DASH, ASES, PSS
Although the precise etiology remains
Pain prior to end ROM Pain at end ROM Minimal pain at end ROM with overpressure
unclear, recent evidence identifies el-
AROM less than PROM, AROM similar to PROM AROM same as PROM
secondary to pain evated serum cytokine levels as part of
Abbreviations: AAROM, active assisted range of motion; AROM, active range of motion; ASES,
the process.19,49,101 Cytokines and other
American Shoulder and Elbow Surgeons Score; DASH, Disabilities of the Arm, Shoulder and Hand growth factors facilitate tissue repair and
Questionnaire; PROM, passive range of motion; PSS, Penn Shoulder Score; ROM, range of motion. remodeling as part of the inflammatory
process. Elevated cytokine levels appear
frozen shoulder and idiopathic adhesive shoulder, and intrinsic secondary frozen predominately involved in the cellular
capsulitis are considered identical and shoulder describes patients with a known mechanisms of sustained inflammation
not associated with a systemic condition pathology of the glenohumeral joint soft and fibrosis in primary and some sec-
or history of injury.128 Secondary frozen tissues or structures. Specific causes of ondary frozen shoulder.19,49,75,101 Although
shoulder was defined by 3 subcategories: secondary frozen shoulder may influence the initial stimulus is unknown, Bun-
systemic, extrinsic, and intrinsic ( prognosis. For instance, individuals with ker et al19 postulated that a minor insult
1).128 The 3 subcategories for second- secondary frozen shoulder related to in- could initiate an inflammatory healing
ary frozen shoulder identify a relation- sulin-dependent diabetes are more likely response leading to excess accumulation
ship between some disease process and to have a more protracted and difficult and propagation of fibroblasts releasing
shoulder symptoms. Systemic secondary clinical course.85,86,88 type I and type III collagen. Fibroblasts
frozen shoulder is more common among We also propose another classifica- differentiate into myofibroblasts, caus-
these patients, due to the related under- tion system based on the patient’s irri- ing contraction of newly laid-down type
lying systemic connective tissue disease tability level (low, moderate, and high), III collagen. He proposed an imbalance
processes.13,14,88 Extrinsic secondary fro- that we believe is helpful when making between aggressive fibrosis and a loss of
zen shoulder includes patients whose clinical decisions regarding rehabilita- normal collagenous remodeling may lead
pathology is not directly related to the tion intervention ( ). Irritability is to protracted stiffening of the capsule
136 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

3. significant capsuloligamentous complex
Stages of Adhesive Capsulitis* (CLC) fibrosis and contracture, which are
consistently found in open or arthroscopic
shoulder surgery and histologic examina-
Duration of symptoms: 0 to 3 months tions in patients with frozen shoulder.80,115
Pain with active and passive ROM Contracture of the rotator cuff interval
Limitation of forward flexion, abduction, internal rotation, external rotation
(RCI) is prevalent in patients with frozen
shoulder.50,78,86,87,115,116,124 The RCI forms
Examination with the patient under anesthesia: normal or minimal loss of ROM
the triangular-shaped tissue between the
Arthroscopy: diffuse glenohumeral synovitis, often most pronounced in the anterosuperior capsule
anterior supraspinatus tendon edge and
Pathologic changes: hypertrophic, hypervascular synovitis, rare inflammatory cell infiltrates, normal underlying capsule
upper subscapularis border, and includes
the superior glenohumeral ligament and
Duration of symptoms: 3 to 9 months
the coracohumeral ligament. The interval
Chronic pain with active and passive ROM
acts as an anterior-superior hammock, re-
Significant limitation of forward flexion, abduction, internal rotation, external rotation
stricting external rotation with the arm at
Examination with the patient under anesthesia: ROM essentially identical to ROM when patient is awake
the side and preventing inferior transla-
Arthroscopy: diffuse pedunculated synovitis (tight capsule with rubbery or dense feel on insertion of arthroscope) tion.94 Imbrication of the RCI resulted in a
Pathologic changes: hypertrophic, hypervascular synovitis with perivascular and subsynovial scar, fibroplasias and scar 50% loss of external rotation with the arm
formation in the underlying capsule
at the side,45 and RCI release in patients
with frozen shoulder leads to an imme-
Duration of symptoms: 9 to 15 months
diate and dramatic increase in shoulder
Minimal pain except at end ROM
external rotation ROM.43,78,86,87 Others
Significant limitation of ROM with rigid end feel
have noted significant subacromial scar-
Examination with the patient under anesthesia: ROM identical to ROM when patient is awake
ring,50,80 loss of the subscapular recess,64,81
Arthroscopy: no hypervascularity seen, remnants of fibrotic synovium can be seen. The capsule feels thick in insertion of and inflammation of the long head of the
the arthroscope and there is a diminished capsular volume
biceps tendon and its synovial sheath123 in
Pathologic changes: “burned-out” synovitis without significant hypertrophy or hypervascularity. Underlying capsule shows
dense scar formation patients with frozen shoulder. Clinicians
attempting to regain shoulder external
Duration of symptoms: 15 to 24 months rotation should perform stretching and
Minimal pain joint mobilization techniques to target the
Progressive improvement in ROM
RCI as well as the anterior CLC.
Reeves96 elaborated on the natural his-
Examination under anesthesia data not available
tory of frozen shoulder and distinguished
* Reprinted with permission from Hannafin JA, Chiaia T. Adhesive Capsulitis. Clin Ortho Rel Res.
2000;372:95-109. 3 sequential stages: the painful stage, the
stiff stage, and the recovery stage. Han-
nafin and Chiaia43 described 4 stages
and ligaments.19 Using new histological synovial angiogenesis (increased papil- incorporating the arthroscopic stages
and immunocytochemical analysis tech- lary growth), rather than synovitis, are described by Nevaiser,83 the clinical ex-
niques, Hand et al42 found that patients described by others.18,50,124 In addition to amination, and the histologic findings
with frozen shoulder had both chronic confirmation of angiogenesis, frequent ( ). Stage 1, the preadhesive stage,
inflammatory cells and fibroblast cells, positive staining for nerve cells was found demonstrates mild erythematous synovi-
indicating both an inflammatory process in patients with frozen shoulder.42 How- tis. Patients present with mild end-range
and fibrosis. ever, if the synovial pathology is angio- pain and are often misdiagnosed as hav-
Frozen shoulder is typically considered genesis or synovitis, there is agreement ing rotator cuff impingement. Stage 2,
an inflammatory process; however, this that pain accompanies the change. Clini- the acute adhesive or “freezing” stage, is
concept is being challenged. No signifi- cally, the idea that frozen shoulder occurs characterized by a thickened red synovi-
cant inflammatory cells in the capsular in the absence of inflammation is difficult tis. Patients frequently have a high level of
tissue have been identified upon histo- to accept, especially because corticoster- discomfort and a high level of pain near
logical examination.18,19,64,115 Numerous oid injections have been shown to have end-range of movement. Even though this
investigators report the visual presence such a significant positive short-term phase is represented by pain, examination
of synovitis consistent with inflamma- effect.3,15,20,58,104,108,117 under anesthesia reveals connective tissue
tion,43,79,83,123 yet focal vascularity and There is little disagreement regarding changes resulting in loss of motion. Stage
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 137

4. [ CLINICAL COMMENTARY ]
3, the fibrotic or “frozen” stage, is charac-
Characteristic of Primary
terized by less synovitis but more mature
Frozen Shoulder
adhesions. Patients note significant stiff-
ness with less pain. These patients have Patient age, 40-65 years
motion limited by established contracture Insidious or minimal, event resulting in onset
as opposed to pain based on examination Significant night pain
under anesthesia, which reveals equal Significant limitations of active and passive shoulder motion in more than 1 plane
passive motion compared to when awake. 50% or greater than 30° loss of passive external rotation
Severe capsular restriction without appar- All end ranges painful
ent synovitis defines stage 4, the “thaw- Significant pain and/or weakness of the internal rotators
ing” phase. Patients in this phase present
with painless stiffness and motion that
typically improves by remodeling. the night indicates less irritability. It also All were felt to have a capsular end feel
Arthroscopic staging clarifies the con- indicates that the painful synovitis/an- while awake, yet 5 of 6 patients had an
tinuum of frozen shoulder and, although giogenesis is resolving as consistent with increase in passive motion of 10° to 30°
initially considered a 12- to 18-month stage 3. The second factor is whether pain when anesthetized. Partial improvement
self-limited process, mild symptoms or stiffness is the predominant symptom. in motion related to diminished pain, and
may persist for years, depending on the The patient experiencing more stiffness muscle guarding has been reported after
extent of fibroplasia and subsequent re- than pain likely has less symptomatic local or regional anesthetic.109
sorption.15,21,22,39,41,107 Authors report mo- synovitis/angiogenesis and more fibrosis. Cyriax24 described a capsular pattern
tion restrictions in 90% of patients at 6 The third factor is whether the symptoms he believed diagnostic for adhesive cap-
months15 and up to 50% of patients at have been improving or worsening over sulitis. The capsular pattern is defined
greater than 3 years.8,21,107 Mild symptoms the last 3 weeks. Improving symptoms as greater limitation of external rotation
persisted in 27% to 50% of patients at an may indicate that the patient is advanc- than abduction and less-limited internal
average of 22 months to 7 years.39,107 ing from stage 2 into stage 3, and that the rotation. Although the capsular pattern is
irritability level is decreasing. Recogniz- often encountered, it is not consistently
ing the extent of tissue irritability has a seen in patients with frozen shoulder when
direct influence on the plan of care. objectively measured.103 A greater than
50% reduction in passive external rota-
A
lthough specific diagnostic cri- tion or less than 30° of external rotation,
teria do not exist, patients with pri- A full upper-quarter examination is per- when measured with the arm at the side,
mary frozen shoulder demonstrate formed to rule out cervical spine and is a common finding in individuals with
a consistent history and clinical examina- neurological pathologies. With frozen frozen shoulder.8,15,18,24,39,78,96,100,107,119,121
tion ( ).80,83,96 Primary frozen shoul- shoulder, the examination of the shoulder Although authors of textbooks have
der and some secondary frozen shoulder typically reveals significant limitation of described patients with frozen shoulder
(eg, secondary to diabetes mellitus), is both active and passive elevation, usually as having normal strength and pain-
characterized by an insidious onset, a less than 120°18,80,95,100; but motion limita- less resisted motions,24 authors of recent
progressive increase in pain, and gradual tions are stage dependent. Scapular sub- studies, using handheld dynamometry,
loss of motion. A minor traumatic event stitution frequently accompanies active have revealed significant weakness of the
may coincide with the patient’s first rec- shoulder motion.103,120 Passive motions shoulder internal rotators53,59 and eleva-
ognition of symptoms. Pain, specifically should be assessed supine to appreciate tors53,59,111 in these patients. The shoulder
sleep disturbing night pain, frequently the quality of the resistance to motion at internal rotators were significantly weaker
motivates the patient to seek medical ad- the end of passive movement (end feel). in patients with frozen shoulder compared
vice. Most patients are comfortable with Frequently, passive glenohumeral mo- to patients with rotator cuff tendinopa-
the arm at the side or with mid-range tions are very restricted due to pain at or thy; however, significant weakness of the
activities, but often describe a sudden, before end range, and muscle guarding external rotators and abductors was also
transient, excruciating pain with abrupt can often be appreciated at end range. We found relative to the uninvolved side.59
or end-range movements. believe that muscle guarding can mas- Special tests, such as impingement signs
Three specific factors from the history querade as a capsular end feel. The first and Jobe’s test, are not helpful in differen-
may be useful in determining the stage author has had the opportunity to ex- tiating frozen shoulder from rotator cuff
or irritability level of the patient’s condi- amine 6 patients prior to manipulation, tendinopathy because they require pain-
tion. First, the ability to sleep through both preanesthesia and postanesthesia. ful end-range positioning.
138 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

5. Significant loss of passive external ro- Multiple shoulder-specific outcome Although multiple studies demon-
tation with the arm at the side, as well as measures are available, such as the Dis- strate improved outcomes with physical
loss of active and passive motion in other abilities of the Arm, Shoulder, and Hand therapy, these outcomes are not always
planes of movement, differentiates frozen Questionnaire (DASH),68 Simple Shoul- superior to other interventions.3,15,20,46,117
shoulder from other pathologies. How- der Test (SST),62 Penn Shoulder Score,60 Additionally, the optimal use of common
ever, other pathologies resulting in sig- American Shoulder and Elbow Surgeons physical therapy interventions (modali-
nificant loss of external rotation with the (ASES) score,98 and the Constant-Murley ties, exercise, joint mobilization), fre-
arm at the side include proximal humeral score.23 These forms typically include quency and timing of visits, and discharge
fracture, severe osteoarthritis, acute cal- questions relative to the patient’s pain criteria have not been established. The
cific bursitis/tendinitis, and a locked pos- and function and some include impair- proposed physiologic effect and support-
terior dislocation. Early frozen shoulder ment data, such as ROM and strength ing literature for using modalities, exer-
may be difficult to differentiate from ro- measurements. To date, research has cises, and manual techniques in physical
tator cuff tendinopathy because motion not identified a specific outcome tool or therapy will be discussed in the following
may be minimally restricted and strength specified score range that is optimal for sections.
testing may be normal. The patient with individuals with frozen shoulder.
a slight loss of passive external rotation
motion at the side and relatively full mo- Patient education about the natural his-
tion in all other directions should be cau- tory of frozen shoulder is probably an
tioned to return for further evaluation if important treatment aspect, though
T
the patient experiences a rapid progres- he definitive treatment for no studies have specifically addressed
sion of shoulder pain and stiffness. frozen shoulder remains un- this component. Explaining the insidi-
Diagnosing frozen shoulder is often clear even though multiple ous nature of frozen shoulder allays the
achieved by physical examination alone, interventions have been studied in- patient’s fear of more serious diseases.
but imaging studies can further confirm cluding oral medications,10,32,97 corti- Discussing how the painful synovitis/
the diagnosis and rule out underlying pa- costeroid injections, 3,8,20,25,46,58,95,104,117 angiogenesis progresses into fibroplasia
thology. Radiography rules out pathology exercise, 3,15,20,25,28,39,46,55,58,72,95 joint and restricts motion prepares the patient
to the osseous structures. Arthrography mobilization, 15,52,84,118,119,127 disten- for an extended recovery. Instruction in
has been used to determine decreased sion, 37,73 acupuncture,114 manipula- performing a consistent home exercise
glenohumeral joint volume associated tion,30,44,47,48,76,89,102 nerve blocks,26 and program (HEP) is important, because
with adhesive capsulitis.81,118,120 Although surgery.1,7,38,43,50,85-87,90,93,106,123,124 Unfortu- daily exercise is effective in relieving
Binder et al9 observed that over 90% nately, varied inclusion criteria, different symptoms.15,20,55
of patients with frozen shoulder dem- treatment protocols, and various out-
onstrated an increased uptake on the come assessments render study compari-
diphosphonate scans (bone scan), they son difficult. One of the major difficulties Little data exist to supporting the use of
concluded bone scans possess little di- in assessing efficacy is success criterion. frequently employed modalities such as
agnostic or prognostic value for frozen Often success is defined by return of heat, ice, ultrasound, or electric stimula-
shoulder.9 Magnetic resonance imaging “normal” motion rather than pain-free tion. Modalities are suggested to influence
(MRI) helps with the differential diag- functional motion. It may be implausible pain and muscle relaxation; therefore,
nosis by identifying soft tissue abnor- for conservative treatment to rapidly re- they might enhance the effect of exercises
malities of the rotator cuff and labrum.56 store full pain-free motion, considering and manual techniques. Hot packs can be
MRI has identified abnormalities of the the presence of dense fibrotic CLC tissue applied before or during ROM exercises.
capsule and RCI in patients with frozen and the months of collagen remodeling Application of moist heat in conjunction
shoulder.56,70 Recently, ultrasonography required to regain soft tissue length. Even with stretching has been shown to im-
has gained favor because it can help dif- if an intra-articular corticosteroid injec- prove muscle extensibility.51 This may oc-
ferentiating rotator cuff tendinopathy tion relieves pain in someone with stage 3 cur by a reduction of muscle viscosity and
from frozen shoulder. A recent study re- frozen shoulder, the fibrotic/contractured neuromuscular-mediated relaxation.105,121
vealed fibrovascular inflammatory soft tissue continues to limit motion. Estab- Gursel et al40 demonstrated the lack of ef-
tissue changes in the RCI in 100% of 30 lishing treatment effectiveness is also ficacy of ultrasound, as compared to sham
patients with frozen shoulder.57 difficult because the majority of patients ultrasound, in treating shoulder soft tis-
A comprehensive history and exami- with frozen shoulder significantly im- sue disorders. Transcutaneous electrical
nation should include a patient-oriented prove in approximately 1 year; therefore, nerve stimulation (TENS), together with
shoulder functional outcome measure. natural history must be considered. a prolonged low-load stretch, resulted
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 139

6. [ CLINICAL COMMENTARY ]
in less pain and improved motion in pa-
Treatment Strategies
tients with frozen shoulder.99
Based on Irritability Level
The basic strategy in treating structural
Modalities Heat/ice/electrical Heat/ice/electrical ...
stiffness is to apply appropriate tissue stimulation stimulation
stress.74 It is helpful to think of the total Activity modification Yes Yes ...
amount of stress being applied as the
ROM/stretch Short-duration (1-5 s), pain- Short-duration (5-15 s), End range/overpressure,
“dosage,” in much the same way that dos- free, passive AAROM passive, AAROM to increased-duration,
age applies to medication. The primary AROM cyclic loading
factors that guide this process are pain Manual techniques Low-grade mobilization Low- to high-grade High-grade mobilization/
and ROM. Adjusting the dose of tissue mobilization sustained hold
stress results in the desired therapeutic Strengthen ... ... Low- to high-resistance end
ranges
change (increased motion without in-
creased pain). Three factors should be Functional activities ... Basic High demand
considered when calculating the dose, or Patient education
total amount of stress delivered, to a tis- Other Intra-articular steroid ... ...
sue: intensity, frequency, and duration. injection
The total end range time (TERT)34,66 is the Abbreviations: AAROM, active assisted range of motion; AROM, active range of motion.
total amount of time the joint is held at
or near end-range position. TERT is cal-
culated by multiplying the frequency and
duration of the time spent at end range
daily, and is a useful way of measuring the
dose of tissue stress.34,66 Intensity remains
an important factor in tensile stress dose
but is typically limited by pain. Tradition-
al ROM exercises are considered lower
forms of tensile stress, while the highest
tensile stress doses are achieved by low-
load prolonged stretching (LLPS), be-
cause TERT is maximized. Therefore, the
goal with each patient is to determine the
therapeutic level of tensile stress.
Applying the correct tensile-stress
dose is based upon the patient’s irritabil-
ity classification ( ). In patients with
high irritability, low-intensity and short-
duration ROM exercises are performed
to simply alter the joint receptors’ input,
reduce pain, decrease muscle guarding,
and increase motion.126
show commonly performed exercises for
patients with high irritability. Stretches
may be held from 1 to 5 seconds at the
relatively pain-free range, 2 to 3 times a
day. A pulley may be used, depending on
the patient’s ability to tolerate the exer-
cise. These exercises primarily influence
different regions of the synovial/CLC
and have been used in supervised physi- (A) Forward flexion, (B) external rotation, (A) Internal rotation, (B) horizontal
(C) extension. adduction, (C) pulley for elevation.
cal therapy programs and an HEP in
140 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

7. patients with frozen shoulder.20,28,39,55,104 satisfaction. Patient satisfaction may ul-
Aggressive stretching beyond the pain timately be the most important measure.
threshold resulted in inferior outcomes Griggs et al39 reported that 90% of 75
in patients with frozen shoulder, particu- patients (mean follow-up, 22 months),
larly if performed in the early phase of the classified with stage 2 idiopathic frozen
condition.28 As the synovitis/angiogenesis shoulder, demonstrated good outcomes
and pain reduce, the fibrotic connective with an exercise program in a prospective
tissue wall is reached (stage 3). Tissue functional outcome study. All patients
stress is progressed primarily by increas- were referred to physical therapy and
ing stretch frequency and duration, while performed HEP of passive stretching ex-
keeping the intensity in tolerable limits. ercises in forward elevation, external ro-
The patient may be asked to hold the tation, horizontal adduction, and internal
stretch for longer periods and increase the rotation. Ten percent of the patients were
number of sessions per day. The patient not satisfied with the outcome, and 7%
is instructed to avoid excessive scapular of these patients underwent manipula-
compensation while performing exercises tion and/or arthroscopic release. Patients
to minimize carryover of abnormal move- with the worst perceptions of their shoul-
ment patterns as motion returns. der before treatment tended to have the
Stick for prolonged elevation/external
As the patient’s irritability level be- worst outcomes.
rotation.
comes low, more-intense stretching and Levine et al61 reported that 89.5% of 98
LLPS using a pulley or device ( ) patients with frozen shoulder responded
are performed to influence tissue remod- Outcomes have been reported in pa- with nonoperative management.61 Reso-
eling. Tissue remodeling refers to a physi- tients with frozen shoulder treated pri- lution of symptoms occurred in 52.4%
cal rearrangement of the connective tissue marily with exercise in physical therapy. with physical therapy and nonsteroidal
extracellular matrix (fibers, crosslinks, Diercks and Stevens28 prospectively fol- anti-inflammatory drugs (NSAIDs),
and ground substance). Collagenous tis- lowed 77 patients with idiopathic frozen while 37.1% resolved with NSAIDs, phys-
sues respond to increased tensile loading shoulder for 24 months to compare the ical therapy, and 1 or more corticosteroid
by increasing the synthesis of collagen effects of “intensive physical therapy” to injections. The average time to successful
and other extracellular components.36,74,125 “supervised neglect.” The intensive physi- treatment was 3.8 months. An impres-
The collagen is oriented parallel to the cal therapy group performed active exer- sive finding among several studies is that
lines of stress, and tensile strength is in- cises up to and beyond the pain threshold, patients placed on a therapist-directed
creased. It is important to note that bio- passive stretching, glenohumeral joint HEP had the same outcomes at short-
logic remodeling occurs over long periods mobilization, and an HEP. The “super- (4-6 months) and long-term (12 months)
(months), in contrast to mechanically in- vised neglect” group was instructed not to follow-ups as those treated with other in-
duced change, which occurs within min- exercise in excess of their pain threshold, terventions.15,20,55,104 Kivimaki55 compared
utes.2 Brand12 describes this phenomenon to do pendulum exercises and active ex- patients treated with an HEP to those
as “growth,” not stretch, of the contracted ercises within the painless range, and to who underwent manipulation under an-
tissue. This growth process is consistent resume all activities that were tolerated. esthesia and HEP. Other than a slight
with the recovery process seen in primary These authors found both groups made increase in ROM, the group performing
frozen shoulder. Commercially available significant improvement in ROM and just an HEP did not differ at any follow-
devices, such as the Dynasplint (Dynas- pain; however, 89% of the “supervised up (6 weeks, and 3, 6, and 12 months) in
plint Systems Inc, Severna Park, MD), neglect” group achieved a Constant score pain or working ability.
and continuous passive motion units can of greater than 80, compared to only 63%
provide LLPS; however, these devices re- of those in the intense-physical-therapy
quire specific positioning and dedicated group. A conclusion of this study was Many authors and clinicians advocate
time during the day. Sustained end-range that aggressive stretching beyond a pain joint mobilization for pain reduction
positioning devices are typically not tol- threshold could be detrimental, espe- and improved ROM.31,54,65,84,118,119 Unfor-
erated in the patients with high or mod- cially if applied in the early phase of the tunately, little scientific evidence exists
erate irritability. McClure and Flowers67 condition. to demonstrate the efficacy of joint mo-
have described a simple abduction splint As mentioned earlier, criteria for suc- bilization over other forms of treatment
fabricated from thermoplastic materials cessful treatment is pain reduction and for frozen shoulder. However, patients
that provides a LLPS. improved functional motion and patient treated with joint mobilization, with or
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 141

8. [ CLINICAL COMMENTARY ]
without concurrent interventions, had shoulder. They found improved motion
better outcomes.15,52,84,118,119,127 and function at 12 weeks, and concluded
Specific joint mobilization techniques that end-range mobilization and mobili-
are believed to selectively stress certain zation with motion were more effective
parts of the joint capsule; for example, than midrange mobilization in increasing
an inferior glide with the arm at the side, motion and functional mobility.
while in external rotation, would stress
the RCI ( ). While this may be
true, it may be more beneficial to view Corticosteroid injections have been used
the CLC through the circle concept. The to manage inflammatory processes for
circle concept refers to all regions of the Inferior glide with the arm at the side and many years. The proposed effect of cor-
in external rotation.
CLC providing stability in all directions ticosteroids is to quell the inflammation,
(ie, anterior structures providing anterior resulting in symptom reduction. Often,
as well as posterior stability).112 When this but the mobilization group had greater corticosteroid injections are adminis-
concept is applied to the shoulder with improvement only in passive abduction tered with either a short- or long-acting
limited glenohumeral motion, improved over the exercise group. Vermulen118 pre- local anesthetic lasting 30 minutes to 6
extensibility of any portion of the CLC sented a case series of 7 patients with fro- hours, respectively. An immediate gain in
results in improved motion in all planes. zen shoulder treated using only intense motion following a glenohumeral intra-
This concept appears supported by the end-range mobilization techniques (no articular corticosteroid injection is attrib-
findings of Johnson et al,52 who found exercise or modalities) over a 3-month utable to the anesthetic effect of reducing
significant improvement in external ro- duration. They reported significant im- pain and thereby muscle guarding.109
tation motion in patients with frozen provement in active and passive motion, Over subsequent days, the corticoster-
shoulder after performing posterior glide pain, and joint volume. Vermullen119 also oid’s anti-inflammatory effect diminishes
mobilizations sustained for 1 minute at performed a randomized prospective the painful synovitis/angiogenesis.76
end range of abduction and external ro- study comparing high-grade mobiliza- Multiple studies have investigated the
tation. High-grade joint mobilizations tion techniques to low-grade mobiliza- use of corticosteroids alone (either intra-
(grades III and IV) are used to promote tion techniques (grades I and II). Patients articular or subacromial), in conjunc-
elongation of shortened fibrotic soft tis- were treated over 12 weeks (24 sessions) tion with supervised physical therapy,
sues. High-grade mobilizations should be and followed for 12 months. They found or with an HEP. Lee et al58 found that all
performed with the joint positioned at or significant improvement in motion and 3 exercise groups (2 receiving different
near its physiologic end range. It should disability for both groups and the greatest site-specific corticosteroid injections),
be noted that immediate ROM gains amount of improvement occurred in the treated over a 6-week period, improved
made with manual techniques ( joint mo- first 3 months. The high-grade mobiliza- equally, though better than a fourth
bilization or end-range stretching) repre- tion group did better, but only a minority group treated only with analgesics. The
sent transient tissue preconditioning12,35 of comparisons reached statistical signifi- groups performed active assisted ROM
and must be reinforced by an HEP. Joint cance and the overall differences between and active ROM exercises and resistive
mobilization techniques may be com- the 2 interventions was small.119 Bulgen et exercise. The authors noted the greatest
bined with hold-relax stretching methods al15 found that patients treated with joint motion improvement in the first 3 weeks
to maximize relaxation, so that tensile mobilization and an HEP significantly im- of treatment. Hazelman46 compared
load may be applied to the affected CLC. proved in the first 4 weeks but not more nonspecified physical therapy, cortisone
An example is performing a submaximal than patients receiving intra-articular injections, and manipulation under an-
isometric contraction of the internal ro- and subacromial corticosteroid injections. esthesia and analgesics for 130 patients
tators, preceding an anterior glide, while At 6 months, the mobilization group sig- retrospectively. Although they found no
at external rotation end range. nificantly improved in motion return and significant recovery difference amongst
Several studies have examined the ef- pain reduction, but no difference was the groups, 28% of the patients in the
fect of joint mobilization in patients with noted compared to the other treatment physical therapy group had symptom ex-
frozen shoulder.15,52,84,118,119 Nicholson84 groups, even the group performing just acerbation. Arslan and Celiker3 randomly
compared a group of patients who re- pendulum exercises. Yang et al127 per- allocated patients to receive either an in-
ceived joint mobilization and active exer- formed a multiple-treatment trial using tra-articular glenohumeral joint injection
cise to a group receiving exercise alone. combinations of end-range mobilization, and home exercise, or physical therapy
They found significantly improved mo- midrange mobilization, and mobiliza- and a nonsteroidal anti-inflammatory
tion and pain reduction in both groups, tion with motion in patients with frozen drug. Physical therapy consisted of hot
142 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

9. packs, ultrasound, passive glenohumeral controlled randomized prospective study subacromial corticosteroid injection for
stretching exercises and wall climb. ROM (n = 90). This study compared 4 groups, relieving shoulder disability and physical
and a pain scale were used for outcome glenohumeral intra-articular corticos- therapy for improving external rotation
measures. Patients in both groups im- teroid injection with HEP, glenohumeral motion.104
proved similarly at 2 and 12 weeks. The intra-articular corticosteroid injection Glenohumeral intra-articular corti-
authors concluded that corticosteroid with physical therapy and HEP, intra- costeroid injections, exercise, and joint
injections and home exercise were as ef- articular saline injection with physical mobilization all result in improved short-
fective as physical therapy, but injections therapy, and intra-articular saline injec- and long-term outcomes. However, there
were much cheaper. tion with HEP. To control for the inac- is strong evidence that glenohumeral
Several studies have also advanced curacy of blind intra-articular injections, intra-articular corticosteroid injections
the argument that intra-articular injec- which can be as high as 42%,33 fluoros- have a significantly greater 4- to 6-week
tions may be superior to therapy. Van der copy was used to ensure the accurate lo- beneficial effect compared to other forms
Windt et al117 compared intra-articular cation of the injections of corticosteroid. of treatment.
injections to physiotherapy in a prospec- At 6 weeks, the corticosteroid injection/
tive randomized study on 109 patients physical therapy/HEP and corticoster-
with a stiff, painful shoulder (capsular oid injection/HEP groups demonstrat-
syndrome). Physiotherapy consisted of ed the largest change in Shoulder Pain
twelve 30-minute sessions involving and Disability Index (SPADI) score and e believe that rehabilita-
passive joint mobilization and exercises. were improved significantly over the tion should be guided by the
Thermal modalities and electrostimula- noncorticosteroid groups. At 6 months, evidence in the literature, the
tion could be used at the therapist’s dis- the SPADI scores were similar among extent of tissue irritability (as defined in
cretion. At 7 weeks, 77% of the patients the groups; however, active and passive ), and the response to treatment.
treated with injections were considered motion were better in the corticosteroid shows basic rehabilitation strate-
treatment successes, compared to only injection/physical therapy/HEP group. gies matched with the level of irritabil-
46% treated with physiotherapy, and This study concluded that at 6 weeks, an ity. While there is not strong evidence
significant differences were found in intra-articular injection alone, or in con- supporting the use of modalities, they
nearly all outcome measures. The main junction with physical therapy, was more may be useful in some patients with high
differences between groups were related effective than supervised physical therapy or moderate irritability if there is a clear
to faster initial relief of symptoms with or an HEP; however, there was no benefit decrease in pain with their application.
injections. of one intervention over the others at 12 Patients with high irritability should be
Bulgen et al15 compared paired intra- months. treated with short-duration, relatively
articular and subacromial injections, Ryans et al104 also investigated the pain-free stretching and low-grade joint
joint mobilization, ice/proprioceptive effect of corticosteroid injections but mobilization to reduce symptoms and
neuromuscular facilitation (PNF), and performed both an intra-articular and avoid exacerbation of pain and inflam-
no treatment (pendulum exercise), in subacromial injection. Their methods mation. Exercise found to be too pain-
a prospective randomized study. Pain were similar to those of Carette et al20 (4 ful or resulting in a prolonged painful
and ROM significantly improved by the groups), except they did not use fluorosco- response is held from the program and
fourth week of treatment for all groups py-guided injections, and only 8 sessions reintroduced when irritability reduces.
and continued until 6 months. Improve- (over 4 weeks) of physical therapy were Patients with low irritability should
ment was most obvious in the corticoster- delivered instead of 12. The physical ther- be given longer-duration stretching
oid injection group, reaching statistical apy program included PNF, mobilization, techniques and high-grade mobiliza-
significance for motion, but not pain, interferential electrical stimulation, and tions performed with the joint near end
during the first 4 weeks. No significant exercise. At 6 weeks, the injection groups range. The core exercises include pen-
differences were seen among the groups significantly improved in the Shoulder dulum exercise, passive supine forward
at 6 months. The study concluded that Disability Questionnaire (SDQ) com- elevation, passive external rotation with
there is little long-term advantage of one pared to the other groups; but patients the arm in approximately 40° abduction
treatment over the other; however, cor- treated in supervised physical therapy in the plane of the scapula, and active
ticosteroid injections may best improve gained significantly more external rota- assisted ROM in extension, horizontal
pain and ROM in the first 4 weeks. tion motion. All groups significantly im- adduction, and internal rotation ( -
Carette et al20 confirmed the benefit of proved by 16 weeks, but no difference was ). Patients with moderate
intra-articular corticosteroid injections present between the groups. The authors irritability may be instructed in pulley
in treating frozen shoulder in a well- recommended an intra-articular and use for elevation. As the irritability level
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 143

10. [ CLINICAL COMMENTARY ]
reduces, progressive end-range stretch- ensuring that the force applied by the
ing and mobilization may be performed. surgeon reaches the capsuloligamen-
The authors encourage reassessment of tous structures. Potential complications
motion and end-range discomfort at include glenoid, scapular, and humeral
each session to determine the patient’s fractures, dislocations, postmanipula-
response to treatment. Patients classi- tion pain, hemarthrosis, rotator cuff tear,
fied as having low irritability may be labral tears, and traction injuries of the
instructed in the same exercises and brachial plexus or a peripheral nerve.63,76
the use of pulleys, but will hold at end Manipulation under anesthesia is con-
range for up to 30 seconds. More pro- trolled, forced, end-range positioning of
vocative stretching positions are used, Stretch to target the rotator cuff interval. the humerus relative to the glenoid in
The patient’s hand remains fixed and the elbow is
such as stretching into external rotation an anesthetized patient. Surgeons try to
moved toward the table.
with the arm in adduction (to isolate the use short lever arms to minimize poten-
stretch of the RCI) or with the arm in times per week. Patients with low irrita- tial fracture risk. Frequently, the surgeon
extension and adduction ( ). We bility who have achieved pain reduction first forcefully abducts the shoulder by
believe that strengthening and aggres- but minimal changes in motion are seen stabilizing the scapula against the thorax,
sive functional activity should be avoid- less frequently, typically once every week while elevating the humerus to release
ed when high and moderate irritability or 2, with emphasis on the home pro- the inferior capsule. Next, the surgeon
is present, and introduced gradually gram as long as they are able to adhere to typically manipulates the shoulder into
when individuals have low irritability; it appropriately. Success of treatment is external and then internal rotation.47
however, regaining motion should al- not necessarily based on the restoration Audible and palpable release of the tissue
ways be emphasized. of normal motion but, rather, symptom suggests a good prognosis.63 Arthroscopic
There is no clear evidence to deter- reduction and patient satisfaction. Com- examination following manipulation re-
mine which patients may need formal monly, patients are discharged when the veals significant bleeding into the joint
supervised therapy rather than simply following occur: significant pain reduc- due to tearing of the CLC.63 The use of a
a home program. Therefore, we recom- tion, stagnant motion gains between ses- glenohumeral joint intra-articular injec-
mend this decision be made based on sions, improved functional motion, and tion of corticosteroid following manipu-
the physician and patient preference, improved satisfaction. lation likely minimizes postmanipulation
with input from the therapist after initial If the symptoms and motion are un- joint irritability.48,90 Contraindications to
evaluation. Factors that may favor use of responsive to the various levels of treat- manipulation of a frozen shoulder in-
supervised therapy may be greater dis- ment over time (3-6 months) and quality clude a history of fracture or dislocations,
ability, more comorbidities, lower social of life is compromised, a manipulation moderate bone loss, or inability to follow
support, lower educational level, or high under anesthesia or surgical capsular re- through with postprocedure care. Studies
fear and anxiety. Patients may initially lease should be considered. If the patient assessing manipulation under anesthesia
be offered an intra-articular corticoster- is unwilling to have a manipulation or report success rates ranging from 75% to
oid injection, and clearly those who fail surgery, the patient is discharged but en- 100%, due to varied inclusion criteria,
to progress within approximately 3 to 6 couraged to continue with a daily stretch- intraoperative procedures, and outcome
weeks should be offered this option. A ing program. measures.1,30,48,90,93
return visit to the referring physician for
a corticosteroid injection should be facili- -
tated if the patient’s symptoms worsen.
There is also no clear evidence to Instead of traditional manipulation
suggest proper frequency of supervised under anesthesia, Roubal et al 102 per-
M
therapy visits. We make decisions about anipulation under anesthe- formed translational manipulation
frequency of visits based on a patient’s sia remains a reasonable treat- for the treatment of frozen shoulder.
within-session and between-session re- ment for patients who have not Translational manipulation differs from
sponses to treatment over the first several responded to conservative treatment traditional manipulation in its use of
weeks. In general, patients with moder- and are capable of adhering to a post- translational (gliding) techniques and
ate or high irritability who demonstrate manipulation program of stretching and static end-range capsular stress, with a
pain reduction and within-treatment therapy.30,48,83,90 The anesthesia, either short-amplitude high-velocity thrust, if
ROM changes of greater than 10° to 15°, general or a local brachial plexus block, needed, as opposed to angular stretch-
are seen more frequently, typically 2 completely relaxes the shoulder muscles, ing forces. The translational techniques
144 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

11. are identical to joint mobilization tech- leased. Several authors believe the RCI
niques (anterior, posterior, and inferior and the contracted coracohumeral liga-
gliding). The authors determined that ment are the only structures requiring
1. Andersen NH, Sojbjerg JO, Johannsen HV,
postmanipulation average increase in release.7,86,87,124 Berghs7 demonstrated Sneppen O. Frozen shoulder: arthroscopy and
flexion was 68°, abduction 77°, external impressive short- and long-term results manipulation under general anesthesia and
rotation 49°, and internal rotation 45°. (mean follow-up, 14.8 months) in 25 pa- early passive motion. J Shoulder Elbow Surg.
Placzek et al92 used the same techniques tients with primary frozen shoulder who 1998;7:218-222.
2. Arem AJ, Madden JW. Effects of stress on heal-
and found significant improvement in had just the RCI and coracohumeral ing wounds: I. Intermittent noncyclical tension.
outcomes at both short- (5.3 weeks) and ligament released. Other authors se- J Surg Res. 1976;20:93-102.
long-term (14.4 months) follow-ups. lectively release additional portions Arslan S, Celiker R. Comparison of the efficacy
Boyles et al11 used translational glid- of the CLC, such as the superior and of local corticosteroid injection and physical
therapy for the treatment of adhesive capsuli-
ing as already described on 4 patients middle glenohumeral ligament,6,50 infe- tis. Rheumatol Int. 2001;21:20-23.
with frozen shoulder; however, they rior glenohumeral ligament,38,85,91,122 the Aydeniz A, Gursoy S, Guney E. Which muscu-
performed additional mobilization/ma- intra-articular component of the sub- loskeletal complications are most frequently
nipulation into directions of perceived scapularis tendon,29,85,91,122 and the poste- seen in type 2 diabetes mellitus? J Int Med Res.
2008;36:505-511.
restrictions. Translational manipulation rior capsule.38,122,123 Balci N, Balci MK, Tuzuner S. Shoulder adhesive
under anesthesia appears to be a safe Postoperative protocols can vary from capsulitis and shoulder range of motion in type
and efficacious alternative for the treat- using a continuous passive motion device II diabetes mellitus: association with diabetic
ment of frozen shoulder.11,92,102 and exercise50 to a an initial daily com- complications. J Diabetes Complications.
1999;13:135-140.
prehensive physical therapy program.123 Beaufils P, Prevot N, Boyer T, et al. Arthroscopic
In 37% of the patients, a follow-up intra- release of the glenohumeral joint in shoulder
articular cortisone injection was required stiffness: a review of 26 cases. French Society
at approximately 4.5 weeks.123 for Arthroscopy. Arthroscopy. 1999;15:49-55.
F
7. Berghs BM, Sole-Molins X, Bunker TD. Ar-
ew reports of open surgical re- throscopic release of adhesive capsulitis. J
lease for frozen shoulder exist.80,110 Shoulder Elbow Surg. 2004;13:180-185. http://
Complete or near complete return dx.doi.org/10.1016/S1058274603003094
F
of motion has been described with open rozen shoulder is a commonly 8. Binder AI, Bulgen DY, Hazleman BL, Roberts S.
Frozen shoulder: a long-term prospective study.
release directed toward the RCI and cora- treated musculoskeletal problem,
Ann Rheum Dis. 1984;43:361-364.
cohumeral ligament.86,87 yet the etiology remains uncertain. 9. Binder AI, Bulgen DY, Hazleman BL, Tudor J,
Patients present with a characteristic his- Wraight P. Frozen shoulder: an arthrographic
tory, physical examination, and natural and radionuclear scan assessment. Ann Rheum
Dis. 1984;43:365-369.
Arthroscopic surgery has replaced open course of recovery. Multiple interventions
10. Binder AI, Hazleman BL, Parr G, Roberts S. A
capsular release as the preferred surgi- have been investigated assessing short- controlled study of oral prednisolone in frozen
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der. Initially, arthroscopic surgery was intra-articular injections demonstrate 11. Boyles RE, Flynn TW, Whitman JM. Manipula-
tion following regional interscalene anesthetic
used only after manipulation failed; but short-term (4-6 weeks) benefits and are
block for shoulder adhesive capsulitis: a case
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questions before applying a dynamic splint
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to the hand. In: Hunter JM, Mackin EJ, Cal-
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71.
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146 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy