ADHESIVE CAPSULITIS

Definition/Description
By definition, adhesive capsulitis is a benign, self-limiting condition of unknown etiology
characterized by painful and limited active and passive glenohumeral range of motion of
25% in at least two directions[1][2][3][4][5][6] most notably shoulder abduction and external
rotation.
Adhesive capsulitis, commonly referred to as frozen shoulder, is associated with synovitis and
capsular contracture of the shoulder joint and can be classified as either primary or secondary.
[1][2][3][4][5][7]
In clinical practice it can be hard to differentiate adhesive capsulitis from other
shoulder pathologies.[1] Since the physical therapy management of adhesive capsulitis is much
different than that of other shoulder pathologies it can be detrimental to the patient if they are
misdiagnosed. Therefore, it is important for the clinician to be aware of the hallmarks of
frozen shoulder and recognize the clinical phases that are specific to this condition [1] which
are discussed below.

Epidemiology /Etiology

Glenohumeral Joint
Although the etiology remains unclear, adhesive capsulitis can be classified as primary or
secondary. Frozen shoulder is considered primary if the onset is idiopathic while secondary
results from a known cause or surgical event.[7] Three subcategories of secondary frozen
shoulder include systemic (diabetes mellitus and other metabolic conditions), extrinsic
(cardiopulmonary disease, cervical disc, CVA, humerus fractures, Parkinsons disease), and
intrinsic factors (rotator cuff pathologies, biceps tendonitis, calcific tendonitis, AC joint
arthritis).[2]
Adhesive capsulitis is often more prevalent in women, individuals 40-65 years old, and in the
diabetic population, with an occurrence rate of approximately 2-5% in the general population,
[5][2][8][9][4][10]
and 10-20% of the diabetic population.[9][10] If an individual has adhesive capsulitis
they have a 5-34% chance of having it in the contralateral shoulder at some point in time.
Simulatneous bilateral involvement has been found to occur approximately 14% of the time.

[2]

Other associated risk factors in addition to the ones mentioned above include: trauma,
prolonged immobilization, thyroid disease, stroke, myocardial infarcts, and presence of
autoimmune disease.[5][11]
The disease process affects the anteriosuperior joint capsule, axillary recess, and the
coracohumeral ligament. It has been shown through arthroscopy that patients tend to have a
small joint with loss of the axillary fold, tight anterior capsule and mild or moderate synovitis
but no actual adhesions.[1][10] Contracture of the rotator cuff interval has also been seen in
adhesive capsulitis patients, and greatly contributes to the decreased range of motion seen in
this population.[2]
There is continued disagreement about whether the underlying pathology is an inflammatory
condition, fibrosing condition, or an algoneurodystrophic process. Evidence suggests there is
synovial inflammation followed by capsular fibrosis, in which type I and III collagen is laid
down with subsequent tissue contraction.[1] Elevated levels of serum cytokines have been
noted and facilitate tissue repair and remodeling during inflammatory processes. In primary
and some secondary cases of adhesive capsulitis cytokines have shown to be involved in the
cellular mechanism that leads to sustained inflammation and fibrosis. It is proposed that there
is an imbalance between aggressive fibrosis and a loss of normal collagenous remodeling,
which can lead to stiffening of the capsule and ligamentous structures.[2]

Characteristics/Clinical Presentation
Patients presenting with adhesive capsulitis will often report an insidious onset with a
progressive increase in pain, and gradual decrease in active and passive range of motion.[2][8]
Patients frequently have difficulty with grooming, performing overhead activities, dressing,
and particularly fastening items behind the back.[11][4] Adhesive capsulitis is considered to be a
self-limiting disease with sources stating symptom resolution as early as 6 months up to 11
years. Unfortunately symptoms may never fully subside in many patients.[11][2][12][13][5][8][14][3][4]
The literature reports that adhesive capsulitis progresses through three overlapping clinical
phases:[1][4][13][11][7]

Acute/freezing/painful phase: gradual onset of shoulder pain at rest with sharp pain
at extremes of motion, and pain at night with sleep interruption which may last
anywhere from 3-9 months.

Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of

glenohumeral motion in capsular pattern. Pain is apparent only at extremes of
movement. This phase may occur at around 4 months and last til about 12 months.

Resolution/thawing phase: Spontaneous, progressive improvement in functional

range of motion which can last anywhere from 1 to 3.5 years.

Differential Diagnosis

Some conditions can present with similar impairments and should be included in the
clinicians differential diagnosis. These include, but are not limited to, osteoarthritis, acute
calcific bursitis/tendinitis, rotator cuff pathologies, parsonage-Turner syndrome, a locked
posterior dislocation, or a proximal humeral fracture. [13] [2]

osseous structures.

ed with adhesive capsulitis being extremely limited and painful while bursitis will, while still painful, have larger ranges.

lems (atrophy of muscles or weakness) that are seen several weeks after initial onset of pain.

stage of adhesive capsulitis because there is limited loss of external rotation and strength tests may be normal. MRI and ultr

n.

Examination
Currently the diagnosis of primary adhesive capsulitis is based on the findings of the patient
history and physical examination.[7]
The following outcome measures have been used in studies researching adhesive capsulitis.

Shoulder Pain and Disability Index (SPADI)

Disability of the Arm, Shoulder and Hand scale (DASH)

American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form

(ASES)

Simple Shoulder Test (SST)

Penn Shoulder Scale (PSS)

NPRS

VAS

SF-36

In a recent systematic review, the psychometric properties of the SPADI, DASH, ASES and
SST were examined.[15]Reliability, construct validity and responsiveness were all found to be
favorable for various shoulder pathologies but the review did not address their strength
relative to adhesive capsulitis specifically.
OBSERVATION of Posture and Positioning

Scapular winging of the involved shoulder may be viewable from the posterior and/or
lateral views.[12]

SCREEN: Upper Quarter Exam (UQE) & Neuro Screen (dermatomes, myotomes,
reflexes)

A full UQE should be performed to rule out cervical spine involvement or any
neurological pathologies.[2]

ROM SCREEN: Active/Passive/Overpressure

Cervical, Thoracic, Shoulder ROMs with OP as well as rib mobility should be performed.

Scapular substitution frequently accompanies active shoulder motion.[2]

RESISTED MUSCLE TESTS

Shoulder External Rotation (ER)/ Internal Rotation (IR) / ABduction (ABd) (seated) should
be performed.

Patients with adhesive capsulitis present with weakness in shoulder ER, IR and ABd
relative to the uninvolved side.[2]

[16]

FORMAL ROM: Active/Passive/Overpressure

Shoulder Flex/ABd/ER/IR

The method of measuring ER and IR ROM in patients with suspected adhesive

capsulitis varies in the literature.[10][18][19][20]

Patients with adhesive capsulitis commonly present with ROM restrictions in a

capsular pattern. A capsular pattern is a proportional motion restriction unique to every
joint that indicates irritation of the entire joint.[18] 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).[18][20] In the
case of adhesive capsulitis, ER is significantly limited when compared to IR and ABD,
while ABD and IR were not seen to be different.

JOINT ACCESSORY MOBILITY

Glenohumeral joint:

Anterior

Inferior

Posterior

Posterior Capsule Stretch

In patients with adhesive capsulitis, the anterior and inferior capsule will be the most limited
but joint mobility will be restricted in all directions.[18]
SPECIAL TESTS
Yang et al. investigated the reliability of three function-related tests in patients with shoulder
pathologies via a non-experimental study (See Resources for scoring guide):[21]

Figure 1. Taken from "Reliability of function-related tests in patients with shoulder

pathologies." by Yang et al, 2006, J Orthop Sports Phys Ther, 36, p.572-576.
Hand-to-neck (Figure 1A)

Shoulder flex + abduction + ER

Similar to ADLs like combing hair, putting on a neclace

Hand-to-scapula (Figure 1B)

Shoulder ext + adduction + IR

Similar to ADLs like snapping a bra, putting on a jacket, getting into back pocket

Hand-to-opposite scapula (Figure 1C)

Shoulder flex + horiz ADDuction

NOTE: These tests require appropriate elbow, scapulothoracic, and thoracic mobility. Be sure
to clear these areas first and keep this in mind during evaluation. If a patient is unable to do
the motion it is important to understand that it may be other structures outside of the shoulder
joint limiting this motion.
Reliability of the three tests was excellent, ranging from 0.83-0.9. Correlation between the
three was moderate (r=0.64 to 0.66). [21]
These functional measures appear to be helpful for their objectivity in measuring shoulder
dysfunction. However, even though the test battery is believed to be comprised of movements
fundamental to activities of daily living, the direct relationship between these tests and
activities of daily living cannot be assumed.
Other:
No specific clinical test for adhesive capsulitis has been reported in the literature and there
remains no gold standard to diagnose adhesive capsulitis.[7] While there are no confirmed
diagnostic criteria, a recent study determined a set of clinical identifiers that achieved
consensus among 70 experts in the field for the first or early stage of primary (idiopathic)
adhesive capsulitis.[7] The following are tools that can be used to help determine the stage of
adhesive capsulitis and/or irritability status.
Consensus was achieved on eight clinical identifiers clustered into two discrete domains
(pain and movement) as well as an age component.[7]
1) PAIN

Strong component of night pain

Pain with rapid or unguarded movement

Discomfort lying on the affected shoulder

Pain easily aggravated by movement

2) MOVEMENT

Global loss of active and passive ROM

Pain at end-range in all directions

3) ONSET > 35 years of age

Medical Management (current best evidence)

Although Adhesive Capsulitis is a self-limiting condition, it can take up to two to three years
for symptoms to resolve and some patients may never fully regain full motion.[14] Therefore, it
is important for patients to undergo treatment for pain, loss of motion, and limited function
rather than take the 'wait-and-see' approach. Various interventions have been researched that
address treatment of the synovitis and inflammation and modify the capsular contractions
such as oral medications, corticosteroid injections, distension, manipulation, and surgery.
Even though many of these treatments have shown significant benefits over no intervention at
all, definitive management regimens remain unclear. It has been discussed that the primary
treatment for adhesive capsulitis should be based on physical therapy and anti-inflammatory
measures;[3] however, these outcomes are not always superior to other interventions.[2]
Corticosteroid Injections
Corticosteroid injections have been used to manage inflammation for many years. It is
recommended for adhesive capsulitis based on the belief that inflammation is key in the early
stage of the condition the corticosteroid will have an anti-inflammatory effect, diminishing the
[22]

painful synovitis occurring within the shoulder.[2][5] This "chemical ablation of synovitis"
limits the development of fibrosis (or adhesions) within the capsule, potentially shortening the
natural history of the disease.[5][1] Thus they are thought to be more useful in the early, painful
and freezing stage of the condition due to the involvement of inflammation, rather than in the
latter stages when fibrous contractures are more apparent.[3][14][1][23]
Methyl-prednisolone and Triamicinolone have both been found to be effective for injection.
There is no evidence suggesting the most effective treatment dose or administration site;
however, the majority of the studies used 20-40 mg injected via an anterior or posterior
approach.[14]
Many studies have been performed and reviewed comparing corticosteroid injections to
physical therapy but contradictory results have arisen. Upon further review, it has been
concluded that corticosteroid injections provide significantly greater short-term benefits (4-6
weeks), especially in pain relief, but there is little to no difference in outcomes by 12 weeks
compared to physical therapy.[3][5][2][14][23][24] It is important to note that the majority of studies
looking at corticosteroid injection as a treatment option do not define what stage the patients
are in and had variations in volumes of corticosteroid used. It has been shown that benefits
may not only be dose dependent but dependent on the duration of symptoms as well,[14][1] thus
the earlier the injection is received, the quicker the individual will recover. Contraindications
do exist due to the use of corticosteroids and include a history of infection, coagulopathy, or
uncontrolled diabetes.[14]
Ultimately, corticosteroid injections have shown to have success rates ranging from 4480%[3] with rapid pain relief and improved function occurring mainly in the first weeks of
treatment. Thus, injections should be suggested to patients with pain as their predominant
complaint in the early stage of adhesive capsulitis.[5][2] Though intra-articular steroid injection
may be beneficial early on, its effect may be small and not well maintained[24] and thus should
be offered in conjunction with physical therapy.[5][14]
Recommendation:

Injection for relieving shoulder disability and pain and physical therapy for improving
motion in the painful freezing stage.[2][1]

If patients fail to progress within 3-6 weeks with physical therapy alone or patient's
symptoms worsen, should be offered the option of a corticosteroid injection.[2]

Manipulation Under Anesthesia (MUA)

Manipulation under anesthesia involves a controlled and forced, end-range positioning of the
humerus relative to the glenoid in physiologic planes of motion (flexion, abduction, rotation)
in patients with an anesthetic block to the brachial plexus. The block allows the shoulder
muscles to completely relax so that the force may actually reach the capsuloligamentous
structures.[2] Traditionally long lever arms were used, but now short lever arm techniques are
utilized to minimize potential risks.[2][9] Although success rates are high, ranging from 75[25]
[2]

100%, manipulations are considered a last resort and are not indicated unless symptoms
persist in spite of adequate conservative treatment for six months.[1][2][3][23] This is due to the
numerous risks and complications such as: dislocation, glenoid, scapular, or humeral fracture,
nerve palsy, rotator cuff tear, hemarthrosis, labral tears, and traction injuries of the brachial
plexus or a peripheral nerve.[1][2][3][23] However, it has been shown that manipulations are the
most reliable way to improve range of motion and reduce pain and disability in patients
resistant to phyiscal therapy[1][3] and these complications can be minimized with proper
techniques and precautions. A good prognosis is often indicated if an audible and palpable
release of the tissue occurs during the manipulation.[2]
An extensive post-manipulation program begins immediately after release of the capsule.[2]
[9]
They are often prescribed active assisted range of motion exercises that they are to perform
every two hours at home, when awake, for the next 24 hours. Patients are also instructed to
ice their shoulder for 20 minutes every two hours with their hand resting behind their head.
Post manipulation programs are designed to maintain gains in shoulder mobility and should
specifically address each individual's impairments.[2][9]
Contraindications to manipulation under anesthesia do exist and include: history of fracture or
dislocations, moderate bone loss, or an inability to follow through with post procedure care.[2]
Although manipulation under anesthesia has been shown to be effective in improving function
and motion in patients with adhesive capsulitis, it is necessary to have more randomized
controlled trials comparing this treatment to competing treatments before widespread use is
advocated.[9]

Translation Mobilization Under Anesthesia

An alternative to traditional MUA, translation mobilization under anesthesia, has been

identified in the hopes of avoiding the complications associated with the traditional approach.
This procedure involves the use of "gliding techniques with static end-range capsular stress,
with a short-amplitude high-velocity thrust, if needed, as opposed to the angular stretching
forces in manipulation under anesthesia."[2][9] In other words, two to three 30-second sets of
low-velocity, oscillatory mobilizations (Maitland Grade IV-IV+) are performed initially in the

same directions as traditional manipulation under anesthesia (anteriorly, posteriorly, and

inferiorly). If an immediate increase in passive range of motion is not noted, a high-velocity,
low-amplitude manipulation may be performed. This technique appears to be a safe and
efficacious alternative for treatment of patients resistant to conservative treatment; however,
higher level studies are needed for verification.[2]
Recommendation:

If a patient has persistent symptoms, particularly in decreased shoulder motion, after at

least 6 months of conservative treatment, manipulation under anesthesia is an effective
technique to improve mobility, pain and disability.

Contraindications and complications do exist and should be relayed to the patient.

Arthroscopic Capsular Release

Arthroscopic capsular release is highly preferred over open release in patients with painful,
disabling adhesive capsulitis that is unresponsive to at least 6 months of non-operative
treatment. It has been found to be a reliable and effective method for restoring range of
motion and is especially recommended in diabetics and in post-operative or post-fracture
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[26]

adhesive capsulitis patients.[3][1] It has become the most popular method of treating
nonresponsive adhesive capsulitis despite the lack of higher level trials comparing it to MUA.
[23]
This is because it allows a more controlled and selective release of the contracted capsule
compared to manipulation which ruptures the capsuloligamentous structures nonspecifically
and avoids the complications associated with MUA.[2][1] Debate exists over which structures
should be arthroscopically released with the rotator cuff interval and coracohumeral ligament
being the most common structures released.[2]

Recommendation:

If patient is unresponsive to at least 6 months of conservative treatment, arthroscopic

capsular release alone or in conjunction with manipulation has been shown to be
effective in restoring range of motion.

Avoids complications associated with manipulation under anesthesia and is

recommended in diabetics and post-op or post-fracture adhesive capsulitis patients.

Other
Non-steroidal anti-inflammatory drugs (NSAIDs) have traditionally been given to patients
with adhesive capsulitis but there is no high level evidence that confirms their effectiveness.[1]
[23]
Oral steroids have also been utilized in these patients and result in some improvement in
function, but their effects have not shown long-term benefits and combined with their known
adverse side effects, should not be regarded as routine treatment.[1][23][27]

Another technique that shows some short-term benefit with rapid relief of symptoms is
distension arthrography. This technique involves the injection of a solution (saline alone or
EmbedVideo is missing a required parameter.
[28]

combined w/ corticosteroids) causing rupture of the capsule by hydrostatic pressure.[3] It is

still undetermined whether joint distension with saline solution combined with corticosteroids
provides more benefit than distension with saline alone or corticosteroid injection alone.
[3]
There is a lack of reliable evidence when determining the effectiveness of this technique
and further research needs to be performed to verify any clinical benefit.[3][23][29]
Suprascapular nerve blocks are thought to temporarily disrupt pain signals to allow
"normalization of the pathological, neurological procresses perpetuating pain and
disability."[23] There is some evidence of benefit with suprascapular nerve blocks, though the
exact mechanism behind this benefit remains unclear and higher level evidence is needed to
establish this as a treatment for adhesive capsulitis.
Medical Management Conclusion
According to a Cochrane review by Green et al.,[30] there is little evidence to support or refute
the use of any of the common interventions listed for adhesive capsulitis. There are also no
studies with objective data supporting the timing of when to switch to invasive treatments
such as manipulation under anesthesia or arthroscopic release, and thus these are not
performed until 6 months of conservative treatment have been unsuccessful. Unfortunately
this exposes more than 40% of patients with adhesive capsulitis to a long period of disability.
[3]

Treatment should be tailored to the stage of the disease because the condition has a
predictable progression.[1][23] During the painful freezing stage, treatment should be directed at
pain relief with pain guiding activity. NSAIDs, physical therapy and steroid injection are all
suggested interventions during this stage of adhesive capsulitis.[14][1] Once the patient is in the
adhesive stage, injections are no longer indicated because the inflammatory stage of the
disease has passed. Instead the focus should switch to more aggressive stretching and MUA or
surgical release if symptoms are unresponsive to conservative treatment and quality of life is
compromised.[1][2][3][23]

Physical Therapy Management (current best evidence)

The definitive treatment for adhesive capsulitis remains unclear even though multiple
interventions have been studied. Previously published prospective studies of effective
treatment have demonstrated conflicting results for improving shoulder range of motion in
patients with this condition.[31] Non-operative interventions include patient education,
modalities, stretching exercises, and joint mobilizations.[2][4] Levine et al. reported that 89.5%
of ninety eight patients with frozen shoulder responded well to non-operative management.
[2]
Reviewed studies suggest that many patients have benefited from physical therapy and
showed reduced symptoms, increased mobility, and/or functional improvement.[4] However, a
Cochrane Review by Green et al. states that there is, no evidence that physiotherapy alone is
of benefit for adhesive capsulitis.[30]
Importance of Patient Education

For the treatment of adhesive capsulitis, patient education is essential in helping to reduce
frustration and encourage compliance. It is important to emphasize that although full range of
motion may never be recovered, the condition will spontaneously resolve and stiffness will
greatly reduce with time. It is also helpful to give quality instructions to the patient and create
an appropriate home exercise program that is easy to comply with because daily exercise is
critical in relieving symptoms.[2]
Modalities
Modalities, such as hot packs, can be applied before or during treatment. Moist heat used in
conjunction with stretching can help to improve muscle extensibility and range of motion by
reducing muscle viscosity and neuromuscular-mediated relaxation.[2] In a randomized study
by Bal et al., patients improved with combined therapy which involved hot and cold packs
applied before and after shoulder exercises were performed.[5] However, a study by Jewell et
al., claimed that ultrasound, massage, iontophoresis, and phonophoresis reduced the odds
of improved outcomes for patients with adhesive capsulitis.[11] A Cochrane Review by Green
et al. showed that, There is no evidence of the effect of ultrasound in shoulder pain (mixed
diagnosis), adhesive capsulitis or rotator cuff tendinitis.[30]
Initial Phase: Painful, Freezing
As stated previously, treatment should be customized to each individual based on what
stage/phase of adhesive capsulitis they are in.
Pain relief should be the focus of the initial phase, also known as the Painful, Freezing Phase.
During this time, any activities that cause pain should be avoided and pain-free activities
should be allowed. Better results have been found in patients who performed pain-free
exercise, rather than intensive physical therapy[1] In patients with high irritability, range of
motion exercises performed with low intensity and a short duration can alter joint receptor
input, reduce pain, and decrease muscle guarding. Stretches may be held from one to five
seconds at a pain-free range, two to three times a day.[2] A pulley may be used to assist range
of motion and stretch, depending on the patients ability to tolerate the exercise. Core
exercises include pendulum exercise, passive supine forward elevation, passive external
rotation with the arm in approximately forty degrees of abduction in the plane of the scapula,
and active assisted range of motion in extension, horizontal adduction, and internal rotation.[2]
(See Resources: Figure 1 and Figure 2).
In a single-patient case-report by Ruiz et al.,positional stretching of the coracohumeral
ligament was performed for a patient in the first phase of adhesive capsulitis.[31] The patient's
Disabilities of Arm Shoulder and Hand (DASH) scores improved from 65 to 36 and Shoulder
Pain and Disability Index (SPADI) scores improved from 72 to 8 and passive external rotation
from 20 degrees to 71 degrees. The stretches performed focused on providing positional low
load and prolonged stretch to the CHL and the area of the rotator interval capsule following
anatomical fiber orientation. The rationale behind this was to produce tissue remodeling
through gentle and prolonged tensile stress on the restricting tissues. While a cause and effect
relationship cannot be inferred from a single case, this report may help with further
investigation regarding therapeutic strategies to improve function and reduce loss of range of
motion in the shoulder and the role that the CHL plays in this.[31] (See Resources: Figure 3).

In the case of adhesive capsulitis, physical therapy can also be a complement to other
therapies (such as steroid injections as discussed previously), especially to improve the range
of motion of the shoulder.[3] In a study by Bal et al., concominant exercises to steroid
injections included isometric strengthening in all ranges once motion was reached in 90% of
normal ranges, theraband exercises in all planes, scapular stabilization exercises, and later,
advanced muscular strengthening with dumbbells.[5]
Second Phase: Adhesive
During the adhesive phase, the focus of treatment should be shifted towards more aggressive
stretching exercises in order to improve range of motion. The patient should perform low
load, prolonged stretches in order to produce plastic elongation of tissues and avoid high load,
brief stretches, which would produce high tensile resistance.[1]
A prospective study by Griggs et al., demonstrated success of a non-operative treatment
through a four-direction shoulder stretching exercise program in which 90% of the patients
reported a satisfactory outcome.[3] During the second phase of treatment, movement with
mobilization and end range mobilization have shown to be successful, according to a
randomized multiple treatment trial by Yang et al.[12] In this trial, the patients had statistically
significant improvements in the Flexi-Level Scale of Shoulder Function (FLEX-SF), arm
elevation, scapulohumeral rhythm, humeral external rotation, and humeral internal rotation.
Mobilization with movement also corrected scapulohumeral rhythm significantly better than
end range mobilization did. The goal for end range mobilization was not only to restore joint
play, but also to stretch contracted periarticular structures, whereas the goal for mobilization
with movement was to restore pain-free motion to the joints that had painful limitation of
range of motion.[12]
A controlled, cohort study, performed by Gaspar and Willis[8], showed that physical therapy
paired with dynamic splinting had better outcomes compared to physical therapy alone or
dynamic splinting alone. The patients in this group of combined treatments received physical
therapy twice a week and a Shoulder Dynasplint System (SDS) for daily end-range stretching.
The physical therapy was standardized, based on the protocols of Vermeulen, Hsu, and
Mulligan. Methods for this treatment include moist heat, patient education and re-evaluation
of symptoms, joint mobilization (limited to progressive end-range joint mobilization), passive
range of motion, active range of motion and PNF, and therapeutic exercise. The SDS was
worn twice each day for seven days per week and was set at #1 for the first week in order to
allow the patient to accommodate to the stretching. After accommodation, the setting was
increased to #2, which equals three foot lbs of force. The progression of the stretch as well as
the adjustment for pain or soreness was standardized, and instructions were given to the
patient to follow accordingly. Patients were instructed to increase the duration in the SDS unit
for 20 30 minutes twice each day (with the intention to stretch 60 minutes each day. The
combination of physical therapy with dynamic splinting had significant improvements
in active, external rotation in patients with adhesive capsulitis.[8]
Third Phase: Resolution
During stage three, also known as the Resolution Phase, treatment is progressed primarily by
increasing stretch frequency and duration, while maintaining the same intensity, as the patient
is able to tolerate. The stretch can be held for longer periods, and the sessions per day can be
increased. As the patients irritability level becomes low, more intense stretching and

exercises using a device, such as a pulley, can be performed to assist tissue remodeling
influence [2]. (See Resource: Figure 4).
Helpful Manual Techniques
Mechanical changes that occur as a result of mobilizations may include the break- up of
adhesions, realignment of collagen, or increased fiber glide when specific movements stress
certain parts of the capsular tissue. These techniques are intended to increase joint mobility by
inducing changes in synovial fluid formation. High-grade mobilization techniques (HGMT)
have been shown to be helpful for improving range of motion in patients with adhesive
capsulitis for at least three months.[10] In a study by Vermeulen et al., patients were given
inferior, posterior, and anterior glides as well as a distraction to the humeral head. These
techniques were performed at greater elevation and abduction angles if glenohumeral joint
range of motion increased during treatment. Patients who received HGMT received these
mobilizations at Maitland Grades III and IV according to the subjects' tolerance with the
intention of "treating the stiffness." Patients were allowed to report a dull ache as long as it
did not alter the execution of the mobilizations or persist for more than four hours after
treatment. However, patients who received low-grade mobilization techniques (LGMT) were
given Mailtand Grades I or II without the report of any pain. Statistically significant greater
change scores were found in the HGMT group for passive abduction (at the time of three and
twelve months), and for active and passive external rotation (at twelve months) when
compared with low-grade mobilization techniques. It can then be concluded that high-grade
mobilization techniques appear to be more effective for increasing joint mobility and reducing
disability.[10] Based on prior knowledge regarding the use of Mailtand Grades for
mobilizations, one would assume HGMT would be more beneficial during later adhesive
stages of adhesive capsulitis, while LGMT would provide more benefit during early painful
stages. However, future studies are needed to investigate whether HGMTs applied during
earlier stages of adhesive capsulitis are as effective as in this particular study.[10]
In a randomized clinical trial, Johnson et al. reported that joint mobilizations, in particular
posterior glenohumeral glides, can help decrease deficits in external rotation, more so than
anterior glenohumeral glides.[19] A significant difference in external rotation was shown
between the two groups (anterior glide treatment vs. posterior glide treatment) by the third
treatment session. The individuals in the anterior mobilization treatment group had a mean
improvement in external rotation range of motion of three degrees (SD 10.8 degrees) ,
whereas the individuals in the posterior mobilization treatment group had a mean
improvement of 31.3 degrees (7.4 degrees). Both groups had a significant decrease in pain,
but there was more improvement in external rotation range of motion in the group with the
posterior mobilization treatment.[19] (See Resources: Figure 5 and Figure 6)
Another randomized controlled trial, performed by Zimmerman et al., found results consistent
with the trial by Johnson et al., in which posteriorly directed joint mobilizations showed
greater improvements in external rotation that anteriorly directed joint mobilizations.[31] Yang
et al. performed a multiple treatment trial using combinations of end-range mobilization, midrange mobilization, and mobilization with motion in patients with adhesive capsulitis.[12]
Improved motion and function was found at 12 weeks with end-range mobilization. It was
concluded that end range mobilization was more effective than mid-range mobilization in
increasing motion and functional mobility.[12] The results in a study by Jewell et al., are also
consistent with these randomized control trials and studies that have demonstrated the
beneficial effects of joint mobilization and exercise for patients with adhesive capsulitis.[11]

Rationale Behind Stretching

Research regarding connective tissue stretch duration and intensity has produced three
findings. First, high intensity, short duration stretching aids the elastic response, while low
intensity, prolonged duration stretching aids the plastic response. Secondly, a direct
correlation exists between the resulting proportion of plastic, permanent elongation and the
duration of a stretch. Lastly, a direct correlation exists between the degree of either trauma or
weakening of the stretched tissues and the intensity of a stretch. Mc Clure et al., stated that the
maximum TERT (Total End Range Time) or the total amount of time the joint is held at near
end range position, will be different for each person, and is often affected by personal
circumstances such as a job or other responsibilities that may prevent a patient from
increasing TERT.[31]
Progression
Manual techniques and exercise should only be progressed as the patients irritability reduces.
Patient response to treatment should be based on their pain relief, improved satisfaction, and
functional gains, rather than restoration of range of motion. Usually, patients are discharged
when significant pain reduction is reached, a plateau of motion gains are noticed for a period
of time, and after improved functional motion and satisfaction have reached their peak.
[2]
Progression for stretching via dynamic splinting is based on patient tolerance, as well. In
the controlled cohort study by Gaspar and Willis, if the patients experienced discomfort or
stiffness lasting more than an hour after the splint was removed, the duration of treatment was
reduced for the next two scheduled stretching sessions. After the patient was able to tolerate
stretching for a total of 60 minutes (30 minutes twice a day), the patient then increased the
tension every two weeks based on tolerance, without discomfort lasting more than one hour
following every stretching session.[8]
What We Need
Despite extensive research, we still need prospective randomized studies comparing
different treatments to formulate precise guidelines about the diagnosis and treatment of
idiopathic adhesive capsulitis."[3] The lack of validity, poor standardization of terminology,
methodology, and outcome measures in the investigations undermines clinical application.
Therefore, more rigorous investigations are needed to compare the cost and effectiveness of
physical therapy interventions.[4]
REHABILITATION PROTOCOL FOR ADHESIVE CAPSULITIS
File:Rehabilitation Protocol for Adhesive Capsulitis.doc [2][31][1][5][12][10][8]
From the information we have gathered from the literature review of rehabilitation for
adhesive capsulitis, we have put together an example of a physical therapy protocol for
practicing clinicians. It is broken up by phase of the disorder and also includes suggestions for
the home exercise program.

Key Research

Vermeulen et al. (2006). Comparison of high-grade and low-grade mobilization techniques in

the management of adhesive capsulitis of the shoulder: Randomized clinical trial.
The purpose of this RCT was to compare high-grade and low-grade mobilization techniques
in patients with adhesive capsulitis. One hundred subjects who had symptoms for >3 months
and >50% loss of passive range of motion were included and assessed at baseline as well as 3,
6, and 12 months post-treatment. Primary outcome measures included the Shoulder Rating
Questionnaire (SRQ), Shoulder Disability Questionnaire (SDQ), active and passive range of
motion. Overall, both groups showed improvements at 12 months with the high-grade
mobilization group being slightly more effective at reducing disability and improving joint
mobility.
Blanchard et al. (2010). The effectiveness of corticosteroid injections compared with
physiotherapeutic interventions for adhesive capsulitits: A systematic review.
The authors of this study deemed six articles eligible for inclusion according to the PEDro
scale for methodological quality. All studies had random allocation to either an injection
group or a physical therapy intervention group. There was a medium effect for corticosteroid
injections compared to physical therapy for the outcomes of pain, passive external rotation
and shoulder disability at six weeks. There was a small effect favoring corticosteroid
injections for pain, passive external rotation and shoulder disability at 12-16 weeks and 26
weeks, and pain and shoulder disability at 52 weeks.
Cleland et al. (2002). Physical therapy for adhesive capsulitis: A systematic review.
The authors of this study reviewed 12 non-operative experiemental or descriptive researchbased outcomes studies published between 1990 and 2000 to determine the efficacy of
physical therapy for patients with adhesive capsulitis. Quality scores from the 12 studies
ranged from 38-69% (mean 54%). Of the studies that were reviewed, physical therapy was
beneficial at reducing symptoms, increasing mobility and/or improving function. However,
poor standardasion of terminology, methodology and outcome measures undermines the
validity of these studies and limits their clinical application.

Resources

FIgure 1: Forward Flexion; External Rotation; Extension

Figure 2: Internal Rotation; Horizontal Adduction; Pulleys for Elevation

Figure 3: Coracohumeral Ligament Stretch

Figure 4: Elevation and ER with Cane

Figure 5: Posterior Mobilizations

Figure 6: Anterior Mobilizations

Description and scoring of the three function-related tests for the first stage of primary adhesive capsulitis.
(Note: Adapted from "Reliability of function-related tests in patients with adhesive capsulitis" by Yang et al., 2002,
JOSPT, 36, p.573)
Hand-to-neck (shoulder flexion + external rotation)*
0 The fingers reach the posterior median line of the neck with the shoulder in full abduction and external rotation
without wrist extension.
1 The fingers reach the median line of the neck but do not have full abduction and/or external rotation.
2 The fingers reach the median line of the neck but with compensation by adduction in the horizontal plane or by
shoulder elevation
3 The fingers touch the neck
4 The fingers do not reach the neck
Hand-to-scapula (shoulder extension + internal rotation)
0 The hand reaches behind the trunk to the opposite scapula or 5cm beneath it in full internal rotation
1 The hand almost reaches the opposite scapula, 6-15 cm beneath it
2 The hand reaches the opposite illiac crest
3 The hand reaches the buttock
4 Subject cannot move the hand behind the trunk
Hand-to-opposite scapula (shoulder horizontal adduction)

0 The hand reaches to the spine of the opposite scapula in full adduction without wrist flexion
1 The hand reaches to the spine of the opposite scapula in full adduction
2 The hand passes the midline of the trunk
3 The hand cannot pass the midline of the trunk
* This test measures an action essential for daily activities, such as using the arm to reach, pull, or hang an
object overhead or using the arm to pick up and drink a cup of water.
This test measures an action essential for daily activities, such as using the arm to pull an object out of a
back pocket or tasks related to personal care.
This test measures an action important for daily activities, such as usin gthe arm to reach across the body
to get a car's seat belt or using the arm to turn a steering wheel.

Clinical Bottom Line

There is no definitive treatment for adhesive capsulitis. However, the literature suggests
interventions should be tailored to the stage of the disease based on its progressive nature.
During the initial/painful freezing stage, treatment should be directed at pain relief with pain
guiding activity. NSAIDs and steroid injection, stretching, strengthening and range of motion
exercises, as well as Maitland Grade I-II mobilizations have been shown to improve function
and reduce pain and disability. As the patient progresses to the adhesive stage, intervention
should focus on aggressive, end-range stretches combined with Maitland Grade III-IV
mobilizations. At six months, if functional disability persists despite conservative treatment,
mobilizations under anesthesia (MUA) or arthroscopic capsular release may be indicated.

Recent Related Research (from Pubmed)

Arthroscopic treatment of bony loose bodies in the subacromial space.

Triceps tendon rupture: the knowledge acquired from the anatomy to the surgical
repair.

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