Orthopedics Decury 1: Adhesive Capsulitis

Agabin, Troy Vincent

Grageda, Yna
Ong, Marie Collins
Mesina, Daniella
Uy, Sean Wesley
Villacamapa, Alessandra Joy

04/19/2013
S> AP, a 47 y/o (-) DM/Htn/Asthma handed pt c/o gr. 5/10 intermittent kirot at ngalay pain
(0=no pain; 10= worst pain on SPS) on shoulder in simple movements but to gr. 7/10
upon movement to endrange as to reaching overhead; (L) lumalagatok knee c pain @ gr.
3/10, pt claims pain is relieved c ice & sometimes subsides when playing basketball. HPI: a
mo. ago, pain was felt again on his shoulder & gradually until 2 wks ago, when he felt
the pain was not tolerable anymore. He consulted a MD last April 12 & referred him to Dr.
Reyes of MMC, where he was Dx c adhesive capsulitis on shoulder last April 17; no meds
were given. X-ray was done but results were still to be read. PMHx: condition started last
Jan 2012 during pts volleyball training, he spiked c his shoulder & felt something like a
pulled muscle; placed ice pack right away. His coach advised him to take a 3-day rest, p
resting, he exercised c a yellowish theratube for a wk & felt okay. Lifestyle: (-) alcoholic
beverages drinker/smoker, works as an outside plant engineer, which requires driving,
computer & office works. Pt still plays basketball during his spare time. Home & social
environment: Pt lives c his wife & mom in a 2-storey house & claims he uses his (L)
shoulder to reach their overhead cabinets; computer @ work follows proper ergonomics.
Goal: Magheal ung sugat at makalaro nang maayos.
O> VS> BP= a: 120/80mm Hg
p:140/100mmHg
OI>endomorph
(-) redness of (B) UE
(-) trophic skin changes on (B) UE
(-) swelling & atrophy on (B) UE
Palpation> (+) gr1 tenderness on bicipital groove area
(+) crepitations upon shoulder ER&IR
(-) muscle spasm on shoulder
(-) muscle guarding on shoulder towards all planes
ROM> All joints of (B) UE are assessed and found significance c shoulder:
AROM
PROM
Endfeel
Flex
0-150
0-160
Firm c pain @ endrange
Ext
0-30
0-35
Firm c pain @ endrange
Abd
0-90
0-108
Firm c pain @ endrange
ER
0-90
0-95
Firm c pain @ endrange
IR
0-80
0-85
Firm c pain @ endrange
MMT> All major muscles of (B) UE are graded 5/5 except:
shoulder flexor 4/5
shoulder abductor 4/5
shoulder extensor 4/5
Sig: Weakness maybe d/t pain.
Special tests> (+) Yergasons test on
(+) Speeds test on
(-) Neer impingement test on
FA> Pt is indep in all aspects of ADLs, bed mob & transfers
Able to reach overhead but c pain
Able to don & doff shirt c mod difficulty

A> PT Dx: MD Dx of adhesive capsulitis on shoulder further defined by inability to do

overhead activities normally 2 to pain & LOM on shoulder
Problem list:
1. Pain
2. LOM
3. Functional limitation (difficulty in doing overhead activities)
LTG> Rehabilitative: Pt will be able to reach overhead, move shoulder towards all
planes s pain& play basketball c ease p 6 PT sessions
>Preventive: Pt will adhere to HEP& apply pt education p 1 PT session to avoid
further complications
STG>
1. Pt will report pain from 7/10 to 3/10 p 3 PT sessions to help him do his work better
2. Pt will demonstrate AROM by ~10 on all movements of shoulder p 3 PT sessions to
aid in his work especially in doing overhead as to putting cables & wires.
P> Pt will be seen & treated as an OP for 6 PT sessions c ff mx:
shoulder
1. US x 1MHz x 1.5 w/cm x 5 on bicipital groove to pain
2. HMP x 20 on shoulder to pain
3. TENS x 20 on shoulder to pain
4. Joint mobilization grade 2 of shoulder towards ant, post, inf gliding x 30secs oscillation
x 2 reps to ROM
5. Arm pull of shoulder x 1 rep to relax muscles & joints
6. GPS towards shoulder abd, flex &ext x 15secs x 3 sets each to ROM
7. Overhead pulley towards shoulder flex &abd of shoulder x 10reps x 2 sets to ROM
8. Shoulder wheel towards shoulder ER & IR x 10reps x 2 sets to ROM
9. Finger ladder towards shoulder abd& flex c 6SH x 10 reps x 2 sets to ROM (L) knee
(L) knee
1. HMP x 20 on shoulder & (L) knee to pain
2. Hamstring sets x 10 reps x 2 sets c 6SH o strengthen hamstrings
3. Short arc quads x 10 reps x 2 sets c 6SH to strengthen quadriceps
4. SLR c ext rot x 6SH x 10 reps x 2 sets to strengthen quadriceps
HEP>
1. Wand exercises
2. Self-stretching
3. Pt education:
4. Respect fatigue
5. Stretch properly prior to game & training

Basic Science/Background
We all know that muscles initiate the movement of a certain body area. In the case of the
shoulder, we can divide it into three parts. First are the muscles connecting the upper limb to the
thoracic wall namely the Pectoralis major which is supplied by the medial and lateral pectoral
nerves from brachial plexus and its action is to adduct the arm and rotate it medially. Next is the
Pectoralis minor which is supplied by medial pectoral nerve from brachial plexus and it
depresses point of shoulder if scapula is fixed and it elevates the ribs of origin (third, fourth and
fifth ribs). Next is the Subclavius which is supplied by the nerve to subclavius from upper trunk
of the brachial plexus and it depresses the clavicle and steadies this bone during movements of
the shoulder girdle. Last is the Serratus anterior which is supplied by long thoracic nerve and it
draws the scapula forward around the thoracic wall and rotates the scapula.
Next are the muscles that connect the upper limb to the vertebral column. There are five, first is
the Trapezius which is supplied by the spinal part of the accessory nerve (motor) and C3-C4
nerve root (sensory). The trapezius has three different parts that has different actions. It is
divided into the upper fibers which elevate the scapula, middle fibers pull the scapula medially
and the lower fibers pull medial border of the scapula downward. Next is the Latissimus Dorsi
muscle, it is supplied by the thoracodorsal nerve and it extends, adducts and medially rotate the
arm. Next is the Levator scapula which is supplied by C3-C4 nerve roots and dorsal scapular
nerve. The Levator scapula also raises the medial border of the scapula. Next are the
Rhomboids major and minor. They are supplied by dorsal scapular nerve and they both raise
the medial border of the scapula upward and medially.
Last are the muscles that connect the scapula to the humerus. First is the Deltoid muscle which
is supplied by the axillary nerve. The Deltoid muscle abducts the arm, the anterior fibers flex
and medially rotate the arm while the posterior fibers extend and laterally rotate the arm. Next
are the infraspinatus and supraspinatus which are both supplied by the subscapular nerve.
Their actions are to abduct the arm and stabilize the shoulder joint, and laterally rotate the arm
and stabilizes shoulder joint respectively. Next are the Teres major and subscapularis muscles,
they are supplied by lower subscapular nerve and upper and lower subscapular nerve
respectively. They both medially rotate the arm and stabilize the shoulder joint. Last is the Teres
Minor which is supplied by the axillary nerve and it laterally rotates the arm and stabilizes
shoulder joint.
Blood supplying these muscles are thoracoacromial trunk (pectoral branch and deltoid branch),
thoracodorsal artery, subscapular artery, circumflex scapular artery and muscular branches of
brachial artery.
These muscles are attached to the bones to help stabilize the shoulder girdle. We have the
Scapula which is attached to the posterior thoracic wall. The spine of the scapula extends to
form the acromion which will later on be attached to the clavicle to form the acromioclavicular
joint. The spine of the scapula then extends to form the glenoid fossa then the head of the
humerus will be articulating to the glenoid fossa to form the glenohumeral joint. Usually, the
head of the upper arm is larger than the socket, and a soft tissue called labrum surrounds the
socket to help stabilize the joint. The labrum also serves as an attachment site for several
ligaments.
The shoulder complex is composed of five joints two functional joints (scapulothoracic and
suprahumeral joints), and three true joints (sternoclavicular, acromioclavicular and glenohumeral
joints). The scapulothoracic (ST) joint is the articulation between the scapula and the thorax,
while the suprahumeral (or coracoacromial) arch is formed by the coracoid process, the

acromion process, the coracoacromial ligament and the inferior surface of the acromioclavicular
joint. Although not part of the true joints of the shoulder complex, these joints contribute to the
normal function of the shoulder complex. Movements in the scapulothoracic joint affect
movement on both the acromioclavicular (AC) joint and the sternoclavicular (SC) joint making
the ST joint part of a true closed chain with the AC and SC joints and the thorax. The
suprahumeral arch on the other hand protects the subacromial bursa, the rotator cuff tendons,
and part of the biceps brachii (long head) tendon from direct trauma, and serves as a barrier
that prevents the humeral head from dislocating superiorly.
The sternoclavicular joint is composed the articulation between the medial end of the clavicle
and the notch formed by the manubrium sternum and the first costal cartilage. This articulation
forms two saddle-shaped articulation surfaces. This joint is the only structural connection
between shoulder complex and upper extremity, and the axial skeleton. It is reinforced by a
strong fibrous capsule and the three ligament complexes sternoclavicular, costoclavicular and
interclavicular ligaments. It has three rotatory degrees of freedom (elevation/depression,
protraction/retraction and anterior/posterior rotation) and three translator degrees of motion that
occurs in the anterior/posterior, medial/lateral, and superior/inferior directions.
The acromioclavicular joint is a plane synovial joint that connects the scapula to the clavicle. It is
supported by a relatively weak capsule, and reinforced by two ligament complexes the
acromioclavicular and coracoclavicular ligaments. Motions in the acromioclavicular joint produce
three rotary motions occurring around axes oriented to the scapular plane (internal/external
rotation, anterior/posterior tilting, and upward/downward rotation), and three translator motion
occurring in the anterior/posterior, medial/lateral, and superior/inferior directions.
The glenohumeraljoint is a ball-and-socket joint formed by the head of the humerus and the
glenoid fossa of the scapula. It has three rotational degrees of freedom flexion/extension,
abduction/adduction, and medial/lateral roration. It is reinforced by a large and loose capsule
that is taut superiorly and slack anteriorly and inferiorly. Its resting position is 40-55 oabduction
and 30o horizontal adduction. Its closed packed-position is full abduction and external rotation,
making the capsule tight. The capsular pattern of the glenohumeral joint is lateral rotation,
abduction and medial rotation.
Large movements occurring in the glenohumeral joint is brought about by the joints relative
laxity. It is therefore necessary for the joint to be supported by surrounding ligaments and
muscles. Static capsular reinforcements include the superior, middle and inferior glenohumeral
ligaments located inside the capsule as thickened regions, and the coracohumeral ligament.
Dynamic reinforcement is provided by the rotator cuff muscles and their tendons by inserting
directly and blending into the glenohumeral joint capsule.
Ranges of motion for the glenohumeral joint may vary across different individuals. According to
the American Academy of Orthopaedic Surgeons, normal ranges are as follows: 180 o flexion,
60o extension, 180o abduction, 70o medial rotation, and 90o lateral rotation.
The glenohumeral joint largely participates in the scapulohumeral rhythm, a coordinated series
of synchronous motions that occurs during shoulder elevation. This concept demonstrates that
for every 15o of motion between 30-170o of shoulder abduction, the glenohumeral joint
contributes 10o of motion while the remaining 5o comes from the scapulothoracic joint, resulting
in a 2:1 ratio.

Medical Background
Frozen shoulder or adhesive capsulitis is a feared sequelae of shoulder tendinitis, bursitis,
partial tear and even reflex sympathetic dystrophy. It is often idiopathic but prolonged
immobilization is a significant risk factor. It is a very painful condition and there will be a gradual
increase in restriction of motion in all directions, especially external rotation and abduction, as
the disease progresses. According to Braddom, Pathologic evaluation reveals perivascular
inflammation but predominantly fibroblastic proliferation with nodular band formation. According
to the American Shoulder and Elbow Society (ASES), frozen shoulder syndrome is a 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 dislocation. There are 3 stages
of Adhesive capsulitis namely: freezing, frozen and thawing.
FREEZING
Intense pain
even at rest
LOM by 2-3
weeks after
onset
Lasts 10-36
weeks

FROZEN
Pain only with movement

Significant adhesions &

limited GH motions

Atrophy of deltoids,
rotator cuffs, biceps &
triceps.
Lasts 4 to 12 months

THAWING
No pain, no synovitis
Significant capsular
restrictions from
adhesions
Lasts 2 to 24 months

The common impairments in frozen shoulder would be nocturnal pain & disturbed sleep during
acute flares, decreased arm swing, decreased joint play and ROM, faulty postural
compensation, general muscle weakness, etc.
Differential Diagnosis
BicipitalTendinopathy

Osteoarthritis

Bicipital tendinitis, or biceps tendinitis, is an

inflammatory process of the long head of the biceps
tendon
Disorders of the biceps tendon can result from
impingement or as an isolated inflammatory injury.
(+) Speeds Test
(+) Yergasons
Anterior shoulder pain over the bicipital groove (with
possible radiation over Biceps)
Tenderness upon palpation over the LHB tendon
(+/-) Crepitation
Popping, audible snap c shoulder movementd/t overuse
Osteoarthritis is mostly a result of natural aging of the
joint. With aging, the water content of the cartilage
increases, and the protein makeup of cartilage
degenerates
Repetitive use of the worn joints over the years can
irritate and inflame the cartilage, causing joint pain and
swelling.

Pain at the joint itself (Deep, Boring)

Pain c movement
M/c c advanced age (50y/o & above)
LOM
Insidious onset
Degeneration d/t overuse (wear & tear)

Rotator Cuff
Tendinopathy

Inflammation of Rotator Cuff tendons

Most injuries occur in the supraspinatus tendon
(+)Empty Can
(+)Hawkins-Kennedy
(+)Neers
weakness on abduction and ER
LOM (especially c IR)
Pain c movement (especially overhead activities)
Nocturnal pain
Painful arc of shoulder abduction (70-120)
Tenderness over Supraspinatus mm.
d/t overuse

Reflex Sympathetic
Dystrophy Syndrome

a chronic condition characterized by severe burning

pain, pathological changes in bone and skin, excessive
sweating, tissue swelling, and extreme sensitivity to
touch.
a nerve disorder that occurs at the site of an injury
(most often to the arms or legs).
It occurs especially after injuries from high-velocity
impacts such as those from bullets or shrapnel.
However, it may occur without apparent injury.
Tendon contractures

Brachial Plexus Injury

Muscle wasting
Loss of strength
(+) swelling and stiffness in affected joints
Damage to the nerves controlling the shoulder and arm
Paralyzed arm
Lost muscle control in arm, hand or wrist
Numbness in the arm

References:
1. Braddom, Randall L., Leighton Chan, and Mark A. Harrast.(2011).Physical
medicine and rehabilitation. 4th ed. Philadelphia, PA: Saunders/Elsevier, Print.
2. Snell, Richard. (2008). Clincal Anatomy edition 8. Lippincott Williams & Wilkins:
351 West Camden Street Baltimore, MD 21201