Adhesive Capsulitis
Introduction
• Adhesive capsulitis of the
shoulder is defined as fibrosis
and contracture of the
glenohumeral joint capsule,
resulting in progressive stiffness,
pain, and restriction of motion of
the shoulder.
Risk factors
• Diabetes Mellitus
• Thyroid disorders
• Age : 40 – 65 years
• Female
• Previous history of AC in contralateral arm
Stages/Clinical Course
Stages Pain Duration ROM Other findings
Stage 1 • Sharp pain at the • Upto 3 months • Little to no loss of • Arthroscopic –
end range of ROM diffuse synovial
movement • Early restriction of reactions
• Achy pain at rest ER
• Sleep disturbance
Stage 2 “painful” or • Pain and increasing • 3 to 9 months • Gradual loss of • Arthroscopic –
“freezing” stage stiffness motion in all aggressive synovitis
directions due to and angiogenesis
pain
Stage 3 “ frozen” stage • Pain is less • 9 to 15 months • Global loss of • Capsuloligamentous
pronounced motion fibrosis
Stage 4 “thawing” • Pain resolving • 15 to 24 months • Range may or may • Capsuloligamentous
stage not resolve fibrosis and synovial
involvement
Assessment findings
• Gradual onset with progressive worsening of pain and stiffness.
• Pain and stiffness limit sleeping, grooming, dressing, and reaching
activities.
• Glenohumeral passive range of motion (ROM) - limited in multiple
directions, with external rotation the most limited, more particularly in
adduction.
• Passive motions into the end ranges of glenohumeral motions -
reproduce the patient’s reported shoulder pain.
• Joint glides/accessory motions are restricted in all directions.
Assessment
• Pain Assessment: Irritability and
night pain.
• Posture analysis: protracted and
rounded shoulders, cervico-
thoracic spine, scapula position.
• Palpation and Examination: Joint
play, active and passive ROM.
Outcome Measures/Tools
• DASH - Disabilities of the Arm, Shoulder and Hand
• SPADI - Shoulder Pain and Disability Index
• ASES - American Shoulder and Elbow Surgeons Shoulder Score
Management
• Pharmacological: NSAIDs and intra articular cortico-steroids.
• Non pharmacological:
Patient education: clinical course, activity modification to encourage pain-free
motion, matches the intensity of stretching to the patient’s current level of
irritability.
Stretching exercises
Modalities : Short wave diathermy, ultrasound or electrical stimulation combined
with stretching and mobility exercises
Joint mobilization
Translational manipulation
Management based on Irritability
High:
NPRS >= 10 Moderate Mild
Consistent night or resting NPRS 4-6 NPRS <=3
pain Intermittent night or resting pain No night or resting pain
Pain occurs before end range Pain occurs at end range of motion Pain occurs on overpressure
Active range is more limited AROM and PROM similar
than passive range due to AROM same as PROM
pain
Management: Management: Management:
• Modalities: Heat for pain • Heat and electrical stimulation as • Progression to performing high-
modulation, Electrical stimulation needed demand functional and/or
• Patient education on positions of • Patient education on progressing recreational activities
comfort and activity modifications activities to gain motion and function • End-range joint mobilization
to limit tissue inflammation and without producing pain procedures
pain Manual therapy: • • Moderate-intensity joint mobilization • Stretching exercises, progressing
• Low-intensity joint mobilization • Gentle to moderate stretching exercises the duration of the stretches into
• Pain-free passive ROM exercises • Neuromuscular re-education: normal tissue resistance
• Pain-free active assisted ROM scapulohumeral movement while • Neuromuscular re-education
exercises performing reaching activities
References
• Patel R, Urits I, Wolf J, Murthy A, Cornett EM, Jones MR, Ngo AL,
Manchikanti L, Kaye AD, Viswanath O. A Comprehensive Update of
Adhesive Capsulitis and Minimally Invasive Treatment Options.
Psychopharmacol Bull. 2020 Oct
• Kelley MJ, Shaffer MA, Kuhn JE, Michener LA, Seitz AL, Uhl TL,
Godges JJ, McClure PW. Shoulder pain and mobility deficits:
adhesive capsulitis. J Orthop Sports Phys Ther. 2013 May
