Clinical Commentary and Literature Review

8/11/2019 Clinical Commentary and Literature Review

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Clinical commentary and literature review: diagnosis, conservative and surgical management

of adhesive capsulitis

1. Robert C. Manske1,*and

2. Daniel Prohaska2

Article first published online: 2 NOV 2010

DOI: 10.1111/j.1758-5740.2010.00095.x

2010 British Elbow and Shoulder Society. Shoulder and Elbow 2010 British Elbow and Shoulder Society

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Shoulder & Elbow

Volume 2, Issue 4, pages 238254, October 2010

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Shoulder;

range of motion;

rehabilitation;

surgery

Abstract

Adhesive capsulitis is a painful musculoskeletal condition of the glenohumeral joint causing limitation of motion

and pain. To date the aetiology of adhesive capsulitis remains somewhat of a mystery. Standard of care

generally consists of conservative management which can be followed by surgical intervention if adequate

function is not attained. Conservative treatment can often be a long and frustrating course. Patience and

persistence usually prevail with a functional return following either conservative or surgical intervention.

Conflicts of interest

None declared

INTRODUCTION

The shoulder is a unique anatomical structure with an extraordinary range of motion (ROM). Significant morbidity

can and does occur, with loss of mobility at the glenohumeral joint. Adhesive capsulitis is a musculoskeletal

condition that has unfortunately been recognized for the lack of understanding of its aetiology as much as it has

for its disabling capability. Diagnosis is made by numerous physical characteristics, including synovial capsule

thickening, subacromial or subdeltoid bursa adhesions, biceps tendon adhesions, and/or obliteration of the

axillary fold as a result of adhesions[19].For over 130 years, adhesive capsulitis remains an enigmatic shoulder

disorder that causes pain and restricted ROM at the glenohumeral joint[10].Although numerous names have

been given for this condition (Table 1), adhesive capsulitis', coined in 1987 by Neviaser and

Neviaser[11]appears to be the preferred terminology. The present review describes our preferred method for

managing the diagnosis and treatment, both conservative and surgically, for adhesive capsulitis. Because little

high level evidence exists at this time for the optimal treatment of adhesive capsulitis, the present review is based

largely on expert opinion, empirical clinical evidence and, when available, evidence from high quality

rehabilitation and surgical studies examining adhesive capsulitis.

Common alternate names

Adhesive capsulitis

Frozen shoulder

Shoulder periarthritis
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Common alternate names

Adherent subacromial bursitis

Hypomobile syndrome

Table 1. Various names given to adhesive capsulitis

Incidence

Because adhesive capsulitis has been shown to have an incidence of 3% to 5% in the general population and up

to 20% in those with diabetes, this disorder is one of the most common musculoskeletal problems seen in

orthopedics[1216].Some studies have described adhesive capsulitis as a self-limiting disorder that resolves in

1 years to 3 years[14,1721],yet others report that between 20% and 50% of patients suffer long-term motion

deficits that can last at times up to 10 years[2226].

The typical patient with idiopathic disease is a female of 50 years to 70 years of age[18,24].There is generally

no preference for handedness, and bilateral involvement is uncommon[18,24].The cumulative incidence

appears much lower in a Dutch study of shoulder complaints, estimated at 2.4/1000 per year (95% confidence

interval, 1.9 to 2.9)[27].

Adhesive capsulitis classification

Before it is even possible to begin to speculate on treatment methods, the form of adhesive capsulitis must be

determined. Classification of adhesive capsulitis almost always occurs by placing the pathology into one of two

categories: (i) primary, insidious and idiopathic, or (ii) secondary, which is typically the result of trauma or

subsequent immobilization[28].Those with primary adhesive capsulitis report a very slow, gradual onset and

progression of symptoms, with no identified precipitating event or mechanism of injury[29].Often, these

symptoms may progress so slowly that the patient does not seek medical council until pain and motion severely

limit daily activities. This is very different from patients afflicted with a secondary adhesive capsulitis, who usually

notice their symptoms soon after an inciting trauma (fall, surgery) because their ROM does not recover after

injury as expected.

Clinical phases

Adhesive capsulitis presentation is generally broken into three distinct phases[30].The first stage is called the

freezing stage, but is also referred to as the painful stage. Some patients are not seen at this stage because

they tend to self treat in the hope that the symptoms will eventually resolve. As symptoms progressively worsen,

pain with both active and passive ROM becomes more restricted, resulting in medical consultation. This phase is

characterized by an acute synovitis of the glenohumeral joint and may last between 3 months and 9 months[31].

The second phase is the frozen stage or the transitional stage. During this stage, shoulder pain does not

necessarily worsen but, because of pain at the end ROM, use of the arm is limited causing muscular disuse. This

phase lasts anywhere from 4 months to 12 months[31].A historically described capsular pattern of limitation is

that of diminishing motions, with external shoulder rotation being the most limited, followed closely by abduction

and internal rotation. There eventually becomes a point in the frozen stage that pain does not occur at the end of

ROM. The historically described capsular pattern of limitation has been recently challenged. Rundquist and
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Ludewig[32],using patients with adhesive capsulitis, assessed humeral motion with a three-dimensional tracking

device and found the pattern of limitation was far from classical. They reported that the true classic capsular

pattern of limitation was found in only 56% of their population. Additionally, they report that, with the arm in

abduction, internal rotation was the most limited motion in 92% of involved shoulders.

When there is a partial recovery of ROM, the third stage is termed the thawing stage. This stage lasts anywhere

from 12 months to 42 months and is characterized by a steady return of shoulder mobility and function.

A final fourth stage is the maintenance stage during which changes in the frequency and intensity of the

exercise regime can be made with a slow, gradual progression being preferred.

Evaluation

Primary adhesive capsulitis is the presentation of adhesive capsulitis that will be focused on in this section. As

with any shoulder condition, the initial evaluation of adhesive capsulitis has to begin with a systematic thorough

history. Inciting events such as mild trauma are often given in relation to the shoulder pain. This may be assumed

to be trivial to the patient, and may not even be considered to be related to the shoulder pain, yet still the patient

may recall something that is attributed to starting the process.

The physical examination to diagnose adhesive capsulitis is marked by the loss of ROM, both passive and active.

This motion is especially painful as the capsule reaches its stretching point at extremes of range. Other

examimations for concomitant abnormalities can and often are positive in regard to pain, and so may not have

much specificity with respect to a true finding. For example, testing for impingement may be positive with a

Hawkin's or Neer sign; however, the pain may be from the intrinsic process. A possible assessment technique

useful for the evaluation of adhesive capsulitis is termed the Gagey hyperabduction test[33].This test assesses

the amount of laxity that exists in the inferior glenohumeral ligament complex. To perform the test, the patient is

seated with the clinician behind. One of the clinicians hand presses down firmly on the top of the patients

shoulder to stabilize the scapula. The other hand passively abducts the humerus until the scapula is felt to move.

The movement when glenohumeral motion ends and scapulothoracic motion begins is termed range of passive

motion of the shoulder in abduction (RPA). The RPA should be less than 105 of abduction and, if RPA is more

than 105, the test is positive for inferior capsule laxity. Interobserver reliability was found to be excellent

(intraclass correlation coefficient = 0.87to0.90), whereas intraobserver reliability was high as well, at 0.84 to

0.89[33].We have found that, when comparing side to side, the patient with adhesive capsulitis will have a

painful and low RPA on the involved shoulder as a result of severe inferior glenohumeral ligament complex

restrictions. It should be noted that the Gagey test was originally described on patients with instability rather than

those with adhesive capsulitis. The results of the study by Gagey and Gagey[33]may not be able to be

generalized to those with frozen shoulder.

Codman[19]discussed adhesive capsulitis, describing a gradual onset of pain, felt near the insertion of the

deltoid, with an inability to sleep on the affected side, and a restriction in both active and passive elevation as well

as external rotation, yet with normal radiological appearance. Without degenerative joint disease seen on

radiographs, the diagnosis of adhesive capsulitis is highly suspected.
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The diagnosis of adhesive capsulitis is commonly given after other causes can be excluded, such as major

trauma, rotator cuff tear, rotator cuff contusion, labral tear, bone contusion, subacromial bursitis, cervical or

peripheral neuropathy, or a history of previous surgical procedure that may have led to the stiffness. If there is no

indication of the above pathologies and radiographs do not demonstrate osteoarthritis, the diagnosis of adhesive

capsulitis can be given. A screening radiograph rules out other conditions that could cause a loss of motion, such

as dislocation, humeral and glenoid fractures.

NON-OPERATIVE TREATMENT

Medication

Treatment may initially involve the use of anti-inflammatory medications, or corticosteroids. Nonsteroidal anti-

inflammatory drugs (NSAIDs) may be used during any phase as an attempt to relieve symptoms. A summary of

studies related to corticosteroids is provided inTable 2.However, there are currently no high quality studies that

randomize treatment using this pharmacotherapy with placebo or natural history of the condition. Therefore,

accounts of success using this line of treatment, although considered important, are not supported. Most studies

appear to demonstrate that NSAIDs may reduce pain early on better than rehabilitation or placebo, although

these benefits are not necessarily maintained over the long term. Risks and benefits must be strongly considered

when prescribing medications. However, there appears to be consideration for NSAIDs when short-term gain is

necessary.

Study and

date

published

Number

of

shoulders

Active interventionControl

interventionResults

Blockey and

Wright[34];

1954

32

Cortisone acetate (200 mg daily for 3 days,

then 100 mg daily for 11 days, then dose

tapered off in decrements of 12.5 mg every

2 days, total dose = 2.5 g over 4 weeks). If

unsatisfactory progress after 4 weeks,

manipulation under general anaesthesia;

followed by a second 4 week course of

cortisone acetate

Placebo

No statistical analysis of between-group differen

reported, although an earlier clinically important

improvement in both pain and range of motion

noted in the oral steroid group: mean pain scores

(measured on a four-point categorical scale conv

into an interval scale, where none = 0, slight = 1,

moderated = 2, severe = 3) at baseline, 1 week, 4

weeks, and 18 weeks were 1.4, 0.9, 0.5 and 0.6 i

steroid group, and 1.4, 1.3, 0.8 and 0.5 in the co

group; total shoulder abduction was 82, 103, 1

and 153 in the steroid groups and 75, 89, 106

154 in the control group. The number of partici

requiring manipulation after 4 weeks was 6/15 (

and 11/16 (68.8%) in the steroid and placebo gro

respectively (RR = 0.58 (0.29 to 1.17)
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Study and

date

published

Number

of

shoulders

Active interventionControl

interventionResults

Kessel et

al.[35];198132

Prednisolone (15 mg daily for 4 weeks)

and manipulation (after 2 weeks of oral

steroids)

Manipulation

No statistical analysis was carried out but dram

response to manipulation in 7/12 (58.3%) partic

taking oral steroids compared to 5/16 (31.25%) t

placebo. Effect of manipulation on final range o

motion at 6 weeks, 12 weeks, and 18 weeks follo

the procedure also favoured the steroid group bu

again, the differences between groups were nor

not formally analyzed

Binder et

al.[24];198440

Prednisolone (10 mg daily for 4 weeks,

then 5 mg daily for 2 weeksNo treatment

The pattern of improvement in pain at night over

weeks showed a significant difference in favour

prednisolone with a more rapid initial recovery,

although, by 5 months, the difference between th

groups was negligible. Improvement in pain at r

with movement, range of motion, and a cumulati

recovery curve were not significantly different b

groups over 8 months

Buchbinder

et al.[36];

2004

50 Prednisolone (30 mg daily for 3 weeks) Placebo

Greater improvement in overall pain in oral stero

group than in placebo group at 3 weeks. There

greater improvement in disability, range of moti

participant rated improvement in 22/23 (96%) or

steroid, vs 11/23 (48%) in placebo group. At 6

analysis favoured the oral steroid group for most

outcomes but none of the differences was signifi

At 12 weeks, the analysis tended to favour the pl

group. A 3-week course of 30 mg prednisolone

of significant short-term benefit in adhesive caps

but benefits are not maintained beyond 6 weeks

Table 2. Description of published randomized controlled trials of oral corticosteroids for adhesive capsulitis

Conservative physical therapy

It is not uncommon to attempt nonsurgical conservative treatment for many musculoskeletal conditions, and

adhesive capsulitis is no exception. The approach for nonsurgical treatment that we recommend will correspond

to the stage of adhesive capsulitis upon the initiation of treatment. Careful assessment and history is imperative

to ensure placement in the appropriate stage and classification. There are minimal to no high level evidence-
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based studies looking at optimal treatment methods during the various stages of adhesive capsulitis. These are

the stages and treatment approaches that we found useful when treating adhesive capsulitis. These clinical

guidelines are empirically-based and we strongly suggest the need for further investigations into the stages and

treatments of this painful condition.

Stage I: painful stage treatment

Because the hallmark sign of this stage is extreme pain, the initial attempt will be to modulate the patient's pain to

allow gentle manipulation of the involved extremity. Pain modulation can occur in a variety of ways. Physical

therapy modalities can be used to decrease pain and include judicious use of electrical stimulation,

transcutaneous electrical neuromuscular stimulation units and moist heat. However, Jewell et al.[37]report that

the use of modalities such as iontophoresis, phonphoresis, ultrasound, or massage actually reduced the

likelihood of improvements in pain of function by 19% to 32% in pat ients with adhesive capsulitis, seriously

questioning their use as a intervention.

Educating the patient on proper posture, clinical course and prevention of re-exacerbation of symptoms is critical

for success during this stage. Gentle passive ROM exercises are performed and include Codman's passive

exercises. Moist heat to both the anterior and posterior shoulder can be beneficial to relax muscle spasm,

decrease pain and slow nerve conduction velocity times, allowing better tolerance of exercises. Additionally, by

allowing controlled movement of the shoulder, type I and II mechanoreceptors of the joint are stimulated that pre-

synaptically inhibit pain fiber transmission at the spinal level[38,39].Mobilization grades and their use are

reported inTable 3.

Grade Description

Grade I Small-amplitude near starting position of range

Grade II Large-amplitude up to near mid-range well free of limitation

Grade III Large-amplitude into the stiffness or muscle spasm

Grade IV Small-amplitude into stiffness or muscle spasm

Table 3. Description of joint mobilization grades

Supine passive flexion and external rotation with the patient using the uninvolved extremity to move the involved

is usually tolerated better than seated exercises in this phase. If tolerated, active assistive ROM exercises such

as L-bar and pulley exercises can be performed in a limited range. The patient should be instructed by no means

to stretch into pain or discomfort. It is extremely important that aggressive stretching to the point of pain is not

attempted. Although we have no supporting data, it is considered empirically that aggressive painful mobilizations

to the glenohumeral joint may prolong the painful stage. Gentle, single-plane grade I and II joint mobilizations to

the glenohumeral joint can be used to modulate pain. Multiplane and rotational joint mobilization techniques may

be too aggressive at this point in the disease process. Because the stretching and mobilizations at this point are

at lower levels, and thus are less likely to cause irritability, the patient is asked to perform these gentle stretches
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approximately six times to eight times per day. Joint mobilization techniques are further described subsequently

in this review.

Because shoulder pain is the overriding complication and complaint during this stage, strengthening takes a back

seat. Submaximal isometrics within a nonpainful range are useful to help decrease strength loss. Isotonic

exercises near end range are not generally well tolerated and are therefore not recommended during this stage.

Sleep may be problematic in this phase; therefore, suggestions on alterations of sleeping with use of bolsters or

pillows to facilitate more restful sleep is appropriate. Gentle passive ROM in the middle of the night is also

sometimes helpful for stimulating mechanoreceptors and thus alleviating night pain that awakens the patient

during sleeping.

Clinical Pearls for the Painful Stage:

Home exercise programme six times to eight times per day

Do not attempt to push ROM through spasm end-feel

No aggressive stretching or strengthening

No overhead activities

Stage II: transitional or frozen stage treatment

It is during this stage that the patient's pain slowly subsides, although the limitation of motion may remain.

Because the pain has decreased, the patient can generally function within their available ROM well. During this

stage, the joint end-feel that was of the muscle spasm origin last phase is now more capsular in nature. With a

capsular end-feel, the patient can generally tolerate a more aggressive stretching and mobilization technique.

Moist heat may still be helpful, although an active warm-up may be more appropriate, enabling the patient to

realize that they can have some control of their symptoms. When dealing with a musculoskeletal disorder with

such a long prognosis for recovery, every small positive point should be celebrated.

The main key that separates the painful stage from the transitional stage is the lack of pain at end ROM. The

patient that has pain at end ROM is still in the painful stage and exercises and mobilization should continue as

previously described. Although rare, patients have jumped back and forth through stages, especially near the end

of one stage and the beginning of another.

Although not grounded in higher level evidence, our preferred method of conservative treatment in stage II

utilizes more aggressive joint mobilization and ROM techniques than those with stage I pathology. Following the

active warm-up, patients are treated with passive ROM exercises as previously described, with the exception that

resistance at end range can be applied as long as a painful response is not caused. The use of single-plane joint


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mobilization techniques is also encouraged and increased to grade III and IV if tolerated. Sometimes, when

stages have recently changed, the use of grade I and II mobilizations can be used to start a treatment session

and can be followed by more aggressive grade III and IV techniques. Following joint mobilization techniques,

passive ROM to end range and stretching techniques for the muscle tendon unit may be applied via contract

relax and holdrelax techniques. A contractrelax technique is a form of stretching that will move the limb into an

agonist pattern. During this technique, the patient will push by contracting the antagonist muscle (the one to be

stretched) isotonically against the resistance of the clinician. The patient then relaxes the antagonist muscle at

the same time as the clinician passively moves the limb through the available ROM to a point that a soft tissue

limitation is felt once more. A holdrelax technique is similar to the contractrelax, with the simple difference of

the patient performing an isometric contraction of the antagonist muscle (i.e. the one to be stretched) followed by

the passive movement to end range.

Clinical Pearls for the Transitional Stage:

Home exercise programme six times to eight times per day

Progression of this stage dependent upon alteration of spasm joint end-feel to capsular end-feel

Begin light strengthening in later stages if tolerated

Stage III: thawing stage treatment

Durig this stage, there is a gradual increase in ROM with a concomitant continued decrease in shoulder pain.

Because pain is no longer an issue, usually more aggressive forms of joint mobilization may be appropriate at

this time and can include multiplane and rotational joint mobilizations. Because the patient is now achieving some

return of ROM, they are given a slight reprieve from the number of repetitions of home exercises. At this point, we

generally decrease the number of home exercise programme repetitions from four to six per day.

Moist heat or an active warm-up still comprises the beginning of the exercise programme. For recalcitrant ROM

restriction loss, a programme of low-load and long duration stretching can be initiated[4042].This can be

followed by active ROM and strengthening exercises in the newly gained range.

Assessment of shoulder arthrokinematics is important at this stage because ROM has returned to a large extent.

Shoulder hiking and abnormal movements should be discussed and discouraged immediately to decrease the

risk for impingement or progression to rotator cuff pathology. The patient may not even notice that these

abnormal movements are occurring because, occasionally, these alterations are slight. Visual feedback from a

mirror is often used to show the patient the abnormal movement patterns.

Clinical Pearls for the Thawing Stage:

Home exercise programme decreased from four times to six times per day
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Can begin more advanced mobilizations including multiplane, rotational techniques

Stage IV: maintenance stage treatment

The maintenance stage is the last stage that will be discussed. ROM at this point may be limited still, althoughgenerally to a mild degree. Therefore, the general stretching programme may be continued three times to four

times per day. Self-ROM and capsular mobilizations could still be performed. A programme of strengthening of

the rotator cuff and the scapular stabilizers is important.

Clinical Pearls for the Maintenance Stage:

Stress patient compliance

Avoid prolonged immobilization

Avoid over aggressive mobilization

Educate that slow, gradual progression best

Joint mobilization techniques

Joint mobilization is a form of passive movement that is used to treat either painful or stiff synovial joints. For

purpose of this review, mobilization refers to a passive oscillatory movement of one articular surface in relation to

the other joint surface. Oscillatory movements occur in the direction of the given joints accessory motion and

include spinning, gliding, rolling or distraction that is required for normal nonpainful joint movements. Numerous

forms of joint mobilization techniques can be performed when treating adhesive capsulitis, and each form and

grade of technique has a specific purpose. Several mobilizations that work well for gaining capsular mobility for

the patient with motion restriction at the glenohumeral joint will be described. The easiest and most common

techniques for improving joint extensibility are the single-plane joint mobilization techniques, including distraction,

anterior, posterior and inferior glide techniques.

Distraction

Glenohumeral joint distraction techniques are usually performed with the patient lying supine on an examination

table because, in this position, it is felt that patient relaxation is best accomplished. The therapist will apply a

distraction to the proximal humeral head in a direction that is perpendicular to the surface of the glenoid fossa.

One common mistake is to perform this technique through the long axis of the humerus, which is not always

perpendicular to the joint plane. This procedure is best carried out in the resting position of the glenohumeral

joint, which is 30 of flexion and 70 of abduction. This mobilization appears to mobilize the entire joint and does

not necessarily address any specific area of the capsule. This may be an excellent mobilization to begin with

during the joint mobilization treatment session to mobilize in general the glenohumeral joint capsule.


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Anterior and posterior glide

Anterior and posterior glide joint mobilizations more specifically address the anterior and posterior portions of the

joint capsule. These techniques can be carried out in either the supine or prone position. The anterior glide is

performed for a loss of external rotation, whereas the posterior glide is best for loss of internal rotation. Toperform anterior glide mobilization, the patient l ies supine on the examining table. On the involved side, the

therapist will place the arm in the resting position and, after applying slight (picalo) traction, mobilize the humerus

in an anteromedial direction parallel to the joint surface of the glenoid fossa. The posterior glide can be performed

with the patient supine also. The therapist applies a posterolateral force to the humeral head in a direction

parallel to the glenoid fossa of the humerus (Fig. 1). The posterior glide technique can be performed in multiple

ranges of shoulder elevation.

Figure 1. Posterior glide mobilization technique. (Written consent obtained from the patient).

Hsu et al.[43]found that anterior glide joint mobilizations near end range improved abduction range of motion. In

a cadaveric model, Hsu et al.[44]found increases in medial rotation when the posterior glides were performed at

end ROM, and small increases in external rotation when anterior glides were performed in the resting position.

Further support for posterior glide joint mobilizations was recently reported by Johnson et al.[45].They assessed

20 consecutive patients with a primary diagnosis of adhesive capsulitis and randomly assigned them to one of

two groups. All subjects received six therapy treatments consisting of upper body ergometer, ultrasound and joint

mobilizations. One group was treated with anterior glide joint mobilizations, whereas the other was treated with

posterior glide joint mobilizations. On average, the group that received anterior joint mobilizations increased

external rotation motion by 3.0, whereas the posterior joint mobilization group increased external rotation motion

by 31.3.

Inferior glide

The inferior glide technique is carried out by applying an inferior mobilization force to the top of the humerus,

again parallel to the surface of the glenoid fossa. This is generally performed in the resting position previously

described, although it can also be performed in higher ranges of motion as the patient progresses (Figs 2 and 3).

Figure 2. Inferior glide mobilization technique at 90 of abduction (Written consent obtained from the patient).
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Figure 3. Inferior glide mobilization technique at 120 of abduction. (Written consent obtained from the patient).

Multiplane mobilization

Each of the techniques previously described are excellent choices to begin with but, sometimes, the restrictions

are extremely chronic situations and require more than single-plane techniques. Multiplane techniques are

carried out by pre-tensioning a portion of the glenohumeral joint capsule before mobilizing the structures. This

advanced technique can be achieved by applying a slight external rotation to the shoulder, followed by an

anterior glide or applying a slight internal rotation motion before applying a posterior glide. Clinical experience

has demonstrated that, in those patients with severe restrictions, multiplane techniques are an invaluable part ofthe treatment regime. It must be stressed that, when using these multiple plane techniques, less force is

generally required[46].

An important clinical pearl regarding joint mobilization techniques is to continually assess the capsular end-feel

that is being imparted to the patients shoulder. The technique used when performing joint mobilizations of this

nature is to impart a bowing force onto the capsule in an attempt to cause a lengthening to occur[47].Proper re-

assessment is mandatory to fully appreciate the change in capsular tissue length. If continually assessing end-

feel firmness, the therapist can adjust the position of the humerus into more abduction, horizontal abduction or

internal and external rotation during the mobilization technique to more selectively stress various portions of the

shoulder joint capsule.

Posterior cuff mobilization

With adhesive capsulitis and ROM loss, inevitably, the soft tissue musculotendinous tissue becomes shortened

also. Several techniques are used to maintain muscletendon unit flexibility. One commonly used technique is

the supine cross-body stretch that mobilizes both the capsule and the posterior cuff muscles. This is carried out

with the patients arm beginning in 90 of flexion when they are lying supine. The therapist stabilizes the patient's

scapula as the arm is adducted across the body imparting the mobilization. In the large patient, it is often difficult

to maintain scapular stabilization when mobilizing the arm in a direction of horizontal adduction. In this instance, a

patient assisted stretch is utilized. For this mobilization, the therapist will use two hands to firmly stabilize the

lateral scapula border and the patient mobilizes their own humerus across their body (Fig. 4).

Figure 4. Horizontal adduction joint mobilization technique. (Written consent obtained from the patient).

Posterior capsule and rotator cuff stretches
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Several key stretches for the patients home exercise program are the self cross-body stretch (Fig. 5)and the

sleeper stretch, which can be done at performed at 90 (Fig. 6)and 45 (Fig. 7)of shoulder flexion. In a recent

study of normal asymptomatic subjects with limited shoulder internal rotation ROM, McClure et al.[48]found that

the cross-body stretch appears to be more effective than the sleeper stretch. McClure et al. [48]admit that a

small sample in each group (n= 15) may preclude statistically significant differences between both groups. For

that reason, both stretches are recommended until further conclusive evidence can support one method of

stretching over the other. Further support for the cross arm stretch and posterior shoulder joint mobilizations is

provided by Manske et al.[49]who found that a combination of cross arm stretching and joint mobilization

improved limited internal shoulder rotation more than cross arms stretch alone. Studies by Tabary et

al.[50,51]have demonstrated that muscles maintained in a shortened position for prolonged times may actually

lose sarcomeres. Furthermore, stretching of this tissue may allow the sarcomeres to be replaced. Therefore,

stretching of the rotator cuff muscles that surround the joint capsule may be indicated. Clinical studies have

demonstrated that the most effective length of time to maintain static positional stretches is approximately 30

seconds[5255].

Figure 5. Cross-body stretch. (Written consent obtained from the patient).

Figure 6. Sleeper stretch at 90 of abduction. (Written consent obtained from the patient).

Figure 7. Sleeper stretch at 45 of abduction. (Written consent obtained from the patient).

Other studies that demonstrate effectiveness of joint mobilization/manipulation with adhesive capsulitis patients

include that of Nicholson[56],who compared a control group of active exercises against an experimental group of

active exercises with the addition of joint mobilization techniques. Twenty patients with adhesive capsulitis were

placed into one of the two groups. The intervention lasted 4 weeks with two to three visits per week. In both

groups, all motions except internal rotation in the control group improved significantly from baseline. Only passive

abduction in the joint mobilization group increased significantly more than the control group. However, pain

scores decreased significantly more in the mobilization group than in the control group. Roubal et al. [57]followed

eight patients who had a physical therapy manipulation following an interscalene brachial plexus block.
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Immediate increases in passive flexion, abduction, external and internal rotation were seen of 68, 77, 49 and

45, respectively. Following discharge, average passive ROM increases for the same motions were 76, 82, 50

and 49, respectively. Additionally, Roubal et al.[57]reported that all patients were able to report increases in

daily functional activities such as combing hair, dressing and reaching overhead[57].A study by Bulgen et

al.[22]assigned patients with frozen shoulder into one of four groups (steroid injection group, mobilization, ice

therapy and a control group that received no treatment). At the 4-week point, the largest ROM increases were

found in those patients who received injections. By 6 months, no difference in ROM or pain were noted between

the groups. All patients ROM improved throughout the follow-up period. Because the injection group appeared to

improve initially Bulgen et al.[22]reported that steroid injections may be the initial treatment of choice and that

physical therapy should not be began in isolation. Vermeulen et al.[58]treated adhesive capsulitis patients with

joint mobilizations twice a week for 3 months. Active ROM increased for active flexion, abduction and lateral

rotation. Passively, the shoulder motion increased in the planes of flexion, abduction and lateral rotation.

Additionally the mean capsule volume increased from 15 ml to 25 ml.

Scapular mobilization

In a study that randomly placed patients with limited shoulder motion (


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As operative techniques continue to shift from open to arthroscopic procedures, the open surgical release is less

common, although still effective[62].The findings of a contracted coracohumeral ligament, as well as capsule,

are addressed in an open procedure or via an arthroscopic procedure.

Manipulation under anaesthesia has been advocated. This method does allow return of ROM immediately in the

operating room (Figs 8 to 15). Immediate postoperative physical therapy can be initiated with this form of

treatment[63].Manipulation under anaesthesia is not without its disadvantages. Tissues that are stretched when

under anaesthesia may cause significant pain once awakened. This can potentially slow recovery but does have

the advantage of inducing no further surgical trauma to the shoulder and its associated pain that also slows

rehabilitation.

Figure 8. External rotation pre-manipulation.

Figure 9. Flexion pre-manipulation.

Figure 10. Inferior glide manipulation.

Figure 11. Internal rotation manipulation.

Figure 12. External rotation at 0 post-manipulation.
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Figure 13. External rotation at 90 post-manipulation.

Figure 14. Flexion post-manipulation.

Figure 15.Axillary pouch seen after manipulation under anaesthesia. Capsule is disrupted and the axillary nerve

is seen in the middle of the photograph.

Arthroscopy has become well accepted in treating this process. A tightened coracohumeral ligament and rotator

interval with the contracted capsule including the axillary pouch is considered to be the essential lesion with

adhesive capsulitis. These contracted structures can be treated by release with arthroscopic instruments allowing

ROM to return with manipulation if necessary. An arthroscopic release can be performed before, during, or after

manipulation, with positive results (Fig. 8)[6476].There are times when a manipulation may be needed before

the procedure, to allow joint access as a result of tightened capsular structures. This is carried out on an

individual patient basis as determined appropriately by the surgeon. During the same procedure, arthroscopy

allows a full evaluation of the shoulder anatomy. Because of the evaluation that arthroscopy affords, any

abnormalities that may not have been diagnosed and may have led to the development of the condition can be

addressed at the time of the procedure being performed to regain motion. If these abnormalities are present and

addressed, postoperative ROM can be less painful and the recovery time is decreased. If subacromial

impingement findings are present, then subacromial decompression may be indicated at this time.

Because of variation in the presentation of length of symptoms, variations in response to treatment, as well as the

lack of understanding of the exact aetiology of the process of adhesive capsulitis, leads to variations of treatment.

There is still room for further controlled studies that may lead to better outcomes for this condition.

Operative treatment of adhesive capsulitis has been shown to decrease the disease duration, and return ROM

with success. Total recovery of pain-free ROM averages 2.8 months (range 1 month to 6 months), whereas the

time for physical therapy averages 2.3 months (range 2 weeks to 20 weeks). Motions such as forward elevation

have been shown to improve from an average of 92 to 165 and external rotation with the elbow at the side from

12 to 56 in a series of 68 shoulders treated with arthroscopic capsular release[34].As a result of the added

diagnostic abilities of arthroscopy and the favourable return of ROM, improved over manipulation alone, this is

our preferred method of operative treatment.
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POSTOPERATIVE TREATMENT

Subsequent to manipulation under anaesthesia, it is not uncommon to begin the first physical therapy treatment

at the bedside in the recovery room. Treatment of passive ROM in the recovery room allows several key

outcomes. To begin, it makes the patient and the family members realize how important rehabilitation is to this

frustrating condition. Second, it gives the therapist a chance to educate the patient's family members on correct

early exercise technique and selection. Because the patient has generally been given a narcotic medication and

is just coming off of anaesthesia, pain is rarely an issue at this early stage. The primary emphases at this point

are performance and education on passive shoulder flexion and external rotation. Family members are asked to

ensure that the patient receives up to six to eight sessions of passive ROM throughout the next several days.

The patient generally returns for daily outpatient physical therapy visits for up to 2 weeks to ensure adequate

ROM is being performed. Often, because the shoulder is so sore after the initial pain medication levels decrease

shortly after surgery, ROM exercises are not performed aggressively enough. The patient should be instructed to

continue the use of pain medication for the first several weeks so that they can tolerate the capsular stretching

and mobilization needed to maintain excellent gains in motion early after manipulation. Because these exercises

can be uncomfortable for the patient, various pain reducing modalities are often beneficial. The patient should be

weaned out of the sling as soon as possible. As long as no concomitant procedures were performed, the patient

should easily be out of their sling in 1 week to 2 weeks. It is up to the therapist to determine the appropriate

aggressiveness for each patient on an individual basis. Exercises are progressed in accordance with the

conservative protocol, with the exception that, generally, the starting location is in the thawing stage where it is

safe to begin more aggressive manual therapy and ROM techniques. Once the patient can tolerate gentle

strengthening, these exercises can be initiated. In general, by 1 week to 2 week post-manipulation, light

submaximal isometrics for the glenohumeral joint, rotator cuff and scapular muscles can begin, with isotonic

exercises starting around the 2-week to 3-week time-frame. Full unrestricted use of the shoulder should be

attained by the 12-week to 16-week time frame in most cases of isolated manipulation under anaesthesia.

SUMMARY

Regardless of the limited high level scientific evidence to equivocally support one treatment method over the

other, patients in agony as a result of a frozen shoulder will seek assistance in the management of their

debilitating condition. This review has described multiple methods (from conservative to surgical) that are

available for treating adhesive capsulitis. Multiple studies have looked at the efficacy of rehabilitation following

adhesive capsulitis. A list of randomized controlled, prospective and retrospective clinical trials is provided

inTables 4 and 5.In general, most of these studies demonstrate various degrees of improvement in pain scores,

ROM and function following various treatment modes. It appears that a combination of pharmacological,

rehabilitative and or surgical treatment is commonly helpful for the patient afflicted with adhesive capsulitis.

Unfortunately, at this time, there is no single standard treatment regime that appears to be most effective over the
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long term. It has not been clearly shown that any form of treatment may be superior to the natural progression of

this problem as described by Chambler and Carr[77].Chambler and Carr[77]note that this typically is a self-

limiting disease that may ultimately improve insidiously on its own with only minimal restriction of physical

function over the long term.

Study

and date

Number of

shoulders

Duration

of

symptoms

Interventions and

number of treatments

Outcomes

measuredFollow-up Findings

1. AC, acromioclavicular; ER, external rotation; PT, Physical Therapy; ROM, range of motion; SA, Sub Acromial; VAS, visual

analogue scale.

Randomized clinical trials

Bulgen et

al.[22];

1984

42 5 months

Sub-acromial

corticosteroid

injections11,

mobilization11, ice

therapy12 and

control8

Pain 8 months

At 4 weeks, improvements i

occurred in the group treated

steroids. At 6 months, no

significant differences were s

between groups

ROM

Carrette et

al.[78];

2003

93


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Study

and date

Number of

shoulders

Duration

of

symptoms

Interventions and


Outcomes


injections May be as effectiv

physical therapy alone or

combination of both

Physiotherapy20 ROM 6 months

De

Jong[80];

1998

57Not

reportedHigh dose injection25

Pain, sleep,

ROM6 weeks

All reported improvement. H

dose intra articular injection

significantly more effective t

lose dose intra articular injec

Low dose injection32

Jacobs, et

al.[81];

1991

50Mean 6

monthsDistension only18

Medication

use, ROM,

pain,

strength

16 weeks

All subjects decreased analg

consumption. Pain relief was

greater in injection of steroid

Steroid only16

Distension/steroid16

Gam, et

al.[82];

1998

20Not

reportedSteroid alone8

Pain via

VAS,

function,

ROM

12 weeks

VAS showed no differences

between treatments. ROM

significantly improved in all

motions except extension In

distension/steroid group

Distension/steroid12

Ryans et

al.[83];

2005

80


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Study

and date

Number of

shoulders

Duration

of

symptoms

Interventions and


Outcomes


PT20

Placebo injection alone

20

Rizk et

al.[84];

1991

48 13 weeks

Intra-articular steroid and

lidocaine; intrabursal

steroid and lidocaine; and

intra bursal lidocaine

Pain 15 weeks

No difference noted in outco

between intrabursal and intra

articular injections. Injection

steroid lido caine had no adv

over lidocaine along in resto

motion, but in two-thirds of t

steroid treated patients

ROM 6 months

Analgesics

Van der

Windt et

al.[74];

1998

108 5 months

Physical therapy12

treatments vs 3

corticosteroid intra-

articular injections

Pain 52 weeks

At 7 weeks 77% treated with

injections were considered

successes compared with 46

treated with physical therapy.

weeks and 52 weeks, these

differences in outcome meas

were small

ROM

Function

Winters et

al.[73];

1997

114 18 months

Physical therapy 20

treatments vs

manipulation vs

corticosteroid injections.

Injections in either joint

capsule, sub acromial

space, or AC joint

Pain 11 weeks

Patients placed into one of t

groupsshoulder girdle gro

synovial group. Shoulder gir

group divided into manipulat

physiotherapy, patients in th

synovial group divided into

corticosteroid injection,

manipulation or physiotherap

shoulder girdle group

manipulation less duration o
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Study

and date

Number of

shoulders

Duration

of

symptoms

Interventions and


Outcomes


than physiotherapy. In synov

group duration of complaints

shortest after corticosteroid

injection, followed by manip

and physiotherapy

Table 4. Review of trials of injection studies following adhesive capsulitis

Study and date

Number

of

shoulders

Duration

of

symptoms

Interventions and


Outcomes

measuredFollow-up F

Clinical Commentary and Literature Review

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