This document discusses adhesive capsulitis or "frozen shoulder". It defines the condition as pain and loss of shoulder range of motion due to thickening of the shoulder joint capsule. It describes the stages and types of frozen shoulder and associated risk factors like diabetes. Symptoms include shoulder pain and stiffness. Treatment involves physiotherapy including range of motion exercises, stretching, joint mobilization and education. The goal is to improve shoulder function and reduce pain and stiffness over 12-18 months as the condition resolves.

1. 1/13/2021 Frozen Shoulder by Dr. Shazia Khalfe 1

2. Adhesive Capsulitis
By
Dr. Shazia Abdul Hamid Khalfe, PT

3. Objectives
At the end of webinar students will be able to:
• Define Adhesive Capsulitis.
• Explain the types of Adhesive Capsulitis.
• Epidemiology of Adhesive Capsulitis.
• Identify the Clinical Presentation of Adhesive Capsulitis.
• Assess Adhesive Capsulitis.
• Identify different Physiotherapeutic Options for Treatment
of Adhesive Capsulitis.
• Plan the Physical Therapy Treatment for Adhesive
Capsulitis.
• Exercises for Adhesive Capsulitis.
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4. Shoulder Joint
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5. Shoulder Joint
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6. Shoulder Joint
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7. Capsular pattern of Shoulder
• The shoulder joint has a capsular
pattern where external rotation is more
limited than abduction which is more limited
than internal rotation (ER limitations > ABD
limitations > IR limitations).
[https://www.physio-pedia.com]
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8. What is Adhesive Capsulitis?
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9. Adhesive Capsulitis
The first recorded description of a frozen
shoulder was reported by Duplay [Duplay 1872]
in 1872, though the term frozen shoulder was
first used in 1934 by Codman[Codman 1934].
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10. Adhesive Capsulitis
Adhesive capsulitis, also known as frozen
shoulder, is a condition characterized by pain
and significant loss of both active range of
motion (AROM) and passive range of motion
(PROM) of the shoulder.
[David et al, 2009]
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11. Adhesive Capsulitis
• It is the condition of uncertain etiology,
characterized by significant restriction of both
active and passive shoulder motion that
occurs in the absence of a known intrinsic
shoulder disorder.
[Zuckerman JD, 2011]
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12. Types of Adhesive
Capsulitis
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13. Types of Adhesive Capsulitis
• Primary Adhesive Capsulitis.
• Secondary Adhesive Capsulitis.
[Chan HBY et al, 2017]
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14. Primary Adhesive Capsulitis
Primary frozen shoulder is idiopathic in nature.
It is characterized by the development of dense
adhesions, capsular thickening, and capsular
restrictions, especially in the dependent folds of
the capsule, rather than arthritic changes in the
cartilage and bone.
[Kisner & Colby 5th Ed]
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15. Stages of Primary Adhesive Capsulitis
• “Freezing.” Characterized by intense pain even
at rest and limitation of motion by 2 to 3
weeks after onset. These acute symptoms may
last 10 to 36 weeks.
[Kisner & Colby 5th Ed]
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16. Stages of Primary Adhesive Capsulitis
• “ Frozen” there is a decrease in
hypervascularity and synovitis however,
capsular contraction and thickening is noted
on arthroscopic evaluation. There is pain
during movement. Atrophy of the deltoid,
rotator cuff, biceps, and triceps brachii
muscles occurs. This stage lasts 4 to 12
months.
[Kisner & Colby 5th Ed, Mohanty & Pattnaik, 2015]
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17. Stages of Primary Adhesive Capsulitis
• “Thawing.” Characterized by no pain and no
synovitis but significant capsular restrictions
from adhesions. This stage lasts 5 to 26
months or longer. Some patients never regain
normal ROM.
[Kisner & Colby 5th Ed]
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18. Secondary Adhesive Capsulitis
Secondary adhesive capsulitis can occur after
shoulder injuries or immobilisation (e.g. rotator
cuff tendon tear, subacromial impingement,
biceps tenosynovitis and calcific tendonitis).
These patients develop pain from the shoulder
pathology, leading to reduced movement in that
shoulder and thus developing frozen shoulder.
[Chan HBY et al, 2017]
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19. Epidemiology
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20. Epidemiology
• Adhesive capsulitis is often more prevalent in
women, as approximately 70% of individuals
who present with a frozen shoulder, are
females.
• 35-65 years old, approximately 2-5% in the
general population, and 20% within the
diabetic population.
[Gasper et al, 2009, Kelle et al 2009, Bal et al 2008]
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21. In Pakistan
• The estimated prevalence of FS in diabetics
from this data was 41.3%. (Lahore)
• A positive family history were associated with
a significantly higher prevalence of Adhesive
Capsulitis.
[Faisal et al, 2017]
• Frequency of shoulder adhesive capsulitis was
24.9% among diabetic subjects. (Karachi)
[ Shakeel A, et al 2012]
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22. Clinical Presentation
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23. [Sarah Walmsley, et al, 2014, Kisner & Colby]
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24. Assessment
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25. Subjective Data
• Medical History:
• Social History:
• Medications:
• History of Present Illness:
[The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services 2010]
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26. Objective Data
• Pain:
• Observation:
• Postural Assessment:
• Palpation:
• Upper Quarter Neuro screen including reflexes,
myotomes, dermatomes
• Range of Motion
• Muscle Performance/Strength:
• Joint Integrity and Mobility:
• Special tests:
[The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services 2010]
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27. Differential Diagnosis
• A plain X-ray is needed to exclude other
pathologies, such as glenohumeral
osteoarthritis, locked dislocations and
tumours, that can present with active and
passive movement restriction and therefore,
mimic frozen shoulder.
[Luise Hollmann, 2017]
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28. Differential Diagnosis
• Shoulder Dislocation:
• Tendonitis or bursitis:
• Acromioclavicular joint dysfunction:
• Malignancy:
[The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services 2010]
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29. Evaluation / Assessment:
• Diagnosis:
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30. Problem List
• Pain
• Impaired joint play and ROM in capsular pattern
• Postural deviations such as protracted scapula
and anterior tipping of the scapula and rounded
shoulders
• Decreased arm swing during gait
• General muscle weakness, poor endurance in
glenohumeral (GH) musculature with resultant
overuse of the scapular muscles.
[The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services 2010]
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31. Functional Limitations and Disabilities
• Difficulty with ADLs requiring reaching
overhead, behind head and behind back
• Unable to lift weighted objects
• Unable to sustain repetitive UE activities.
[Kisner & Colby Ed 5]
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32. Prognosis:
Adhesive capsulitis can last 12 to 18 months,
with 3 distinct phases. The first phase can last 2-
9 months, the second phase 4-12 months and
the last phase, the thawing phase, from 6-9
months.
[The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services 2010]
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33. Goals
• Demonstrate knowledge of self management of
symptoms
• Demonstrate independent knowledge of home exercise
program
• Increase ROM of all affected motions to equal ROM on
the unaffected side
• Demonstrate normal postural alignment
• Demonstrate normal UE motion during gait
• Demonstrate highest level of muscular performance on
involved UE and scapular musculature
[The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services 2010]
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34. Interventions most commonly used
• ROM exercises including pendulum exercises, PROM, AAROM,
AROM
• TENS for pain relief
• Strengthening exercises within pain free range
• 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 reeducation to regain normal GH and scapulothoracic
biomechanics
[The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services 2010]
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35. Frequency & Duration
• Frequency and duration of treatment are both
dependent on the stage that the patient is in.
[The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services 2010]
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36. Patient / family education
• Time Frames of healing and of each stage
• Pathology and natural history of the disorder
• Role of PT in rehabilitation
• Home exercise program including strengthening
and AROM/AAROM/PROM
• Pain management techniques
• Postural awareness education
[The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services 2010]
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37. Physiotherapeutic
Interventions For Frozen
Shoulder
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38. Pain Relief
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39. Improvement In Shoulder Range Of
Motion
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40. Improvement In Shoulder Function
[Jain & Sharma, 2013]
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41. Exercises
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49. Summary
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50. References
• Bal A, Eskioglu E, Gulec B, Aydog E, Gurcay E, Cakci A. Effectiveness of
corticosteroid injection in adhesive capsulitis. Clinical Rehabilitation 2008;
22:503-512.
• Codman EA. Tendinitis of the Short Rotators. In: The Shoulder: Rupture of
the Supraspinatus Tendon and Other Lesions in or about the Subacromial
Bursa. Boston MA: Thomas Todd, 1934
• David et al, Frozen shoulder: A clinical review Article in British journal of
hospital medicine (London, England: 2005) · June 2009
• DOI: 10.12968/hmed.2009.70.5.42225 · Source: PubMed
• Duplay E. De la periarthrite scapulo-humérale et des raideurs de l`épaule
qui en sont la conséquence. Arch Gen Med 1872; 20: 513-542
• Faisal Inayat,1 Nouman Safdar Ali,2 Haroon Shahid,3 and Fariha Younus4,
2017 Prevalence and Determinants of Frozen Shoulder in Patients with
Diabetes: A Single Center Experience from Pakistan, Cureus. 2017 Aug;
9(8): e1544.
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51. References
• Gaspar P, Willis B. Adhesive capsulitis and dynamic
splinting: a controlled, cohort study. BMC
Musculoskeletal Disorders 2009;10:111.
• Hui Bin Yvonne Chan, Pek Ying Pua, MManipPhty,
Choon How How,2017, Physical therapy in the
management of frozen shoulder, Singapore Med J
2017; 58(12): 685-689 doi: 10.11622/smedj.2017107.
• Kelley M, Mcclure P, Leggin B. Frozen shoulder:
Evidence and a proposed model guiding rehabilitation.
J Orthop Sports Phys Ther 2009;39:135-148.
• Kisner & Colby 5th Ed. Chapter 17.
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52. References
• Luise Hollmann , 2017, Solving the Enigma of Frozen
Shoulder, Sydney School of Medicine The University of Sydney
• Mohanty & Pattnaik, 2015, Physiotherapy for the Shoulder,
Chapter 4.
• Sarah Walmsley, Peter G. Osmotherly, Darren A. Rivett, 2014,
Clinical Identifiers for Early-Stage Primary/Idiopathic Adhesive
Capsulitis: Are We Seeing the Real Picture? Physical Therapy
Volume 94 Number 7
• Shakeel Ahmad, Dr. Mohammad Sohail Rafi, Iqbal Ahmed
Siddiqui, Khurram Hamidi, Nabiha Mujahid Faruq, 2012 The
Frequency Of Adhesive Capsulitis in Diabetes Mellitus
Patients. Pakistan Journal of Rehabilitation 2012 Volume 1
(Issue 2).
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53. References
• The Brigham and Women's Hospital, Inc.
Department of Rehabilitation Services 2010
• www.physio-
pedia.com/Capsular_and_Noncapsular_Patterns#
:~:text=%5B17%5D%20The%20shoulder%20joint
%20has,ABD%20limitations%20%3E%20IR%20lim
itations, Assessed on 9th July 2020]
• Zuckerman JD, Rokito A. Frozen shoulder: a
consensus definition. J Shoulder Elbow Surg
2011; 20:322-5.
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