Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Adhesive Capsulitis of Shoulder


Related Terms

  • Frozen Shoulder
  • Periarthritis

Differential Diagnosis

Specialists

  • Hand Surgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist
  • Rheumatologist
  • Sports Medicine Physician

Comorbid Conditions

Factors Influencing Duration

The presence of comorbid conditions usually prolongs disease and disability duration. Improper or delayed treatment or aggressive surgical treatment may contribute to delayed recovery. Work absence will likely be greater if the dominant shoulder is affected and/or the occupation requires lifting, carrying, and overhead work. If the nondominant side is involved or the individual is employed in sedentary or light work, earlier resumption of employment is anticipated. If surgery is required for adhesive capsulitis or a comorbid condition, additional therapy of perhaps 6 to 12 weeks in duration will be necessary, further delaying return to work and other functions. Outcomes for older individuals are poorer.

Medical Codes

ICD-9-CM:
726.0 - Adhesive Capsulitis of Shoulder

Overview

© Reed Group
Adhesive capsulitis is a condition of the shoulder characterized by stiffness, loss of motion (contracture), and pain, typically with a gradual onset, worsening over time, and with ultimate resolution. Often called frozen shoulder, adhesive capsulitis is clinically divided into two classes, primary and secondary. Individuals with primary adhesive capsulitis, which is characterized by a significant limitation of both active and passive motions of the shoulder, can recall no possible cause of the condition (idiopathic adhesive capsulitis, or adhesive capsulitis without a known cause). Individuals with secondary adhesive capsulitis are able to describe trauma or a possible cause prior to the onset of symptoms, such as fracture of the humerus, rotator cuff repair, shoulder girdle injury/surgery, or prolonged immobilization (e.g., holding an arm at the side while a wrist fracture is healing).

Primary adhesive capsulitis generally undergoes three phases of variable duration. The first phase, a painful "freezing" period lasting 2 to 9 months, begins with increased blood flow within the glenohumeral joint (shoulder joint between the humerus or upper arm bone and the glenoid or socket in the scapula). This frequently is associated with inflammation of the joint capsule and an insidious onset of pain. Pain may be aggravated by psychological stress and exposure to cold or vibration. The second is the adhesive, stiffening, or "frozen" phase, lasting 4 to 12 months. During this phase the glenohumeral joint capsule undergoes fibrosis (scarring) and gradually shrinks, thereby progressively restricting joint motion. The third phase involves recovery or "thawing" and is of variable duration, lasting from several months to 3 years.

Primary adhesive capsulitis has been shown to be associated with autonomic dysfunction, genetic predisposition, or forgotten or unrecognized trauma. Other associated conditions include autoimmune, cerebrovascular, coronary artery, and cervical disc disease, as well as depression, hypothyroidism, and Parkinson's disease. It usually is not associated with osteoarthritis, rotator cuff injury, or malignancies. Although a specific trauma may not be identified, repetitive combined movements (abduction with external rotation) of the shoulder, as in reaching overhead or reaching for a back pocket or dress zipper, can sometimes cause the condition. The non-dominant shoulder is more often involved than the dominant one but the condition can affect both shoulders (bilateral) either sequentially or simultaneously in up to 16% of individuals (Roy). The occurrence of both unilateral and bilateral adhesive capsulitis is more common in individuals with diabetes.

Genetic abnormalities have been found to be associated with adhesive capsulitis, including the presence of specific genes in tissue samples obtained during surgery for the condition (Roy). Conditions that have been suggested to predispose individuals to primary and secondary adhesive capsulitis are trauma, surgery to the shoulder and/or other regions of the body, shoulder conditions that demonstrate similar restricted motion to that of adhesive capsulitis (e.g., bursitis, tendinitis), inflammatory diseases, hyperthyroidism, and dyslipidemia. Precisely why pain precedes stiffening and loss of motion is unclear, leading to the belief that the condition does not stem solely from mechanical defects within the glenohumeral joint itself. Neurologic factors may contribute to the generation of pain (e.g., sympathetic autonomic hyperactivity, alpha-adrenoreceptor hyper-responsiveness, and central nervous system factors). Inadequate blood supply (ischemia) to soft tissue identical to that found in Dupuytren's contracture is also found in adhesive capsulitis, indicating a possible microvascular connection between neurologically mediated pain and connective tissue contracture, as well as a link between adhesive capsulitis and the microvascular aspects of diabetes, especially type 1 diabetes.

Incidence and Prevalence: Prevalence of adhesive capsulitis is reported to be 2% in the general population, increasing to 11% among diabetics. Incidence is even higher among those with type 1 diabetes. These individuals have a 40% lifetime chance of developing the disorder (Roy).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Age increases risk (but is rare before age 40), with most cases of adhesive capsulitis occurring during the fifth and sixth decades of life; average age of onset is 52 years in women and 55 years in men (Roy).

Approximately 70% of patients presenting with adhesive capsulitis are women, and 20% to 30% of those affected will develop adhesive capsulitis in the opposite shoulder (Binder).

Source: Medical Disability Advisor



Diagnosis

History: The individual usually reports a gradual onset with pain followed by progressive stiffness. Sometimes, however, loss of motion may be the first complaint. Discomfort is often vague, but is typically worse at night, especially when the individual lies on the affected side. Pain usually is present with shoulder movement, prompting the individual to immobilize the joint, which potentially increases the stiffness. Although a cause is not usually reported, the physician obtains a general health history and a thorough history of recent and prior illness, surgery, and traumatic injury.

Physical exam: Pain during range of motion may be the only physical finding. Passive and active glenohumeral motions are decreased, often accompanied by pain and associated muscle spasms. Moving the arm away from the body (abduction) and outward (external) rotation are the motions most severely affected. Motion between the scapula and the chest wall (scapulothoracic motion) is not affected by this condition. Diagnostic criteria include loss of 30° or more of external rotation an inability to raise the arm beyond 130° of flexion (both actively and passively). Tenderness that is often generalized rather than localized usually is noted about the rotator cuff. Physical examination may include assessment of signs of illness or injury.

Tests: The diagnosis is often made through history and physical exam alone. Plain x-rays of the shoulder may be taken initially to rule out fracture, arthritis, tumor, or calcium deposits in the rotator cuff tendons and are usually considered normal in primary adhesive capsulitis. With secondary adhesive capsulitis the original injury can be seen on x-rays but no changes are seen for the adhesive capsulitis. X-rays of the cervical spine to rule out other causes are reasonable. Electromyography (EMG) rarely may be needed to evaluate neurological function, but may be indicated if a nerve problem in the neck is suspected as a cause of the shoulder pain and stiffness. Diagnostic blood tests may be ordered to identify possible underlying illness such as diabetes, thyroid disease, hyperlipidemia, infection, or an inflammatory condition such as rheumatoid arthritis. If the diagnosis is in doubt, or there is lack of progress after approximately 3 months of treatment, more sophisticated testing may be performed. For example, an arthrogram may demonstrate diminished shoulder capsule volume; a bone scan, increased uptake; and a magnetic resonance imaging (MRI) scan, increased blood flow.

Source: Medical Disability Advisor



Treatment

Treatment for adhesive capsulitis usually is nonoperative (conservative) and begins with education regarding the condition. Nonsteroidal anti-inflammatory drugs (NSAIDs) often are helpful for relief of pain and inflammation. Narcotic analgesics may be used for individuals intolerant of NSAIDs and for those with severe pain. However, the mainstay of treatment is physical therapy, initiated promptly upon diagnosis, focusing on stretching and then strengthening exercises. The exercises are initially supervised by a physical therapist but later can be performed on a self-directed basis with periodic therapist and/or physician monitoring. Modalities such as ice, heat, and ultrasound also may be used to relieve pain. If pain limits participation in therapy, a combination of local anesthetic and a corticosteroid drug can be injected into the shoulder joint. In such a combination, the anesthetic provides short-term pain relief, while the corticosteroid provides longer-term reduction of inflammation and associated discomfort, ideally permitting more aggressive therapy. If injections are used, it may be advisable to use a relatively large volume in order to distend the contracted shoulder capsule. A suprascapular nerve block sometimes may be employed, injecting bupivacaine into the supraspinous fossa. This is a simple, steroid-free procedure with no notable complications except tenderness at the injection site (Roy). Use of slings or other types of immobilization is typically avoided. The challenge is that it hurts to move but moving is the key to recovery.

If the individual is unable to regain motion after approximately 6 to 12 weeks of therapy, manipulation of the joint under general or regional anesthesia may be beneficial, although the risk of fracture with this technique is high. Individuals with diabetes often do not benefit from manipulation and more commonly require surgery if therapy fails.

Adhesive capsulitis also can be treated surgically by cutting the capsule (capsular release). This is most commonly done using an arthroscope, although arthroscopy is difficult in adhesive capsulitis due to the contracted capsule and small joint volume. Open capsular release also can be performed, although this is rarely indicated since the natural history of adhesive capsulitis is one of progressive improvement.

Source: Medical Disability Advisor



ACOEM

ACOEM's Practice Guidelines, the gold standard in effective medical treatment of occupational injuries and illnesses, are provided in this section to complement the disability duration guidelines.*
 
Shoulder Disorders
 
* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Source: ACOEM Practice Guidelines



Prognosis

Adhesive capsulitis is self-limiting, and most individuals recover function and range of motion with time and conservative treatment within 1 to 2 years, but the range of motion may not fully return to normal. However, during this time, affected individuals can be significantly limited in shoulder activities. About 60% of individuals are left with some permanent loss of shoulder motion (Roy). Individuals with diabetes are particularly predisposed to slow and incomplete recovery.

Source: Medical Disability Advisor



Rehabilitation

The rehabilitation for adhesive capsulitis of the shoulder will vary depending on the phase at which the individual presents for treatment. However, treatment involves active exercise in all three phases, which should be performed on a daily basis in conjunction with physical therapy. The key is to encourage the patient to perform the exercises daily after receiving the appropriate home education program and then have the therapist follow up with modifications in the program.

Phase 1: (painful "freezing" phase, lasting up to 9 months) - Rehabilitation for adhesive capsulitis of the shoulder must include patient education to prevent loss of motion, avoid painful movements, and initiate a home exercise program (Hannafin). Treatment should consist of passive and active assisted range of motion shoulder exercises. Pendulum and gentle closed chain stabilization exercises may be beneficial (Hannafin). Joint mobilization may be used to augment passive range of motion and to prevent impingement of shoulder rotator cuff tendons. The focus should be on reducing pain, preventing loss of motion, and protecting against contractures of the joint capsule (Frontera). Abduction and overhead stretches should also be utilized (Frontera).

Phase 2: ("frozen" phase, lasting up to 12 months) - Continue with treatment as in phase 1. Active exercises may be added. As pain diminishes, passive and active assisted stretching exercises may become more aggressive. Treatment must emphasize pain management, regaining motion, and exercises that promote normal glenohumeral and scapulohumeral movement (Hannafin).

Phase 3: (“thawing” phase, lasting up to 2 years) - More aggressive treatment is recommended and can be tolerated by the patient during this phase of recovery. Rehabilitation must focus on regaining motion and strengthening the shoulder girdle and scapular musculature with return to previous activity levels. Continue to emphasize exercises that promote normal glenohumeral and scapulohumeral movement (Hannafin).

Past research does not support the benefit of ultrasound, electrical stimulation, heat, ice, or iontophoresis for the treatment of adhesive capsulitis. However, modalities may be beneficial for palliative relief of symptoms and to facilitate the individual’s participation in therapy (Frontera). Home exercise programs are critical, must be performed daily, and should reflect the exercise regimen prescribed during each phase of rehabilitation (Hannafin).

Intra-articular corticosteroid injections combined with physical therapy have been shown to speed improvement in shoulder range of motion and pain by 6-week and 3-month follow-up assessments; however, by 12 months, control groups caught up to the treatment groups with comparable outcomes (Buchbinder; Carette). In one study, physical therapy treatment when given alone did not appear to be beneficial (Carette), but in another, physical therapy treatment was effective in increasing shoulder range of motion as compared to intra-articular steroid injection alone (Calis). Hyaluronate injections are not recommended (Calis).

Manipulation under anesthesia (MUA) or glenohumeral distension via intra-articular injection of corticosteroids with saline may be used to loosen adhesions, improve function, and reduce pain (Buchbinder). After MUA, physical therapy is typically initiated the day after the procedure and continued daily for 2 to 4 weeks to retain newly-acquired range of motion (Canale). It is not clear to what extent physical therapy intervention affects outcomes after joint distension (Buchbinder).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistAdhesive Capsulitis of Shoulder
Physical or Occupational TherapistUp to 20 visits within 52 weeks using home program
Nonsurgical (primarily home program)
SpecialistAdhesive Capsulitis of Shoulder
Physical or Occupational TherapistUp to 20 visits within 52 weeks using home program
Surgical
SpecialistAdhesive Capsulitis of Shoulder
Physical or Occupational TherapistUp to 20 visits
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Pain may persist and dysfunction of the upper extremity may result in permanent disability (loss of functional range of motion). Disuse may cause increased stiffness and loss of bone (osteoporosis) about the shoulder. The weaker bones, especially proximal humerus, may fracture should the individual fall or undergo manipulation under anesthesia. Surgical treatment such as arthroscopy or manipulation, particularly if aggressive, can result in more complications than conservative treatment, and thus prolong recovery.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Limitations in lifting, carrying, and reaching overhead depend on the reduction in range of motion; the strength of the shoulder; and the type, frequency, and degree of pain the individual experiences. Arm function can be classified as restricted or absent when individuals exhibit very limited shoulder motion; however, individuals usually retain use of the hand. Individuals performing repetitive motion with the upper extremity are encouraged to maintain good posture during work, and the work area must be ergonomically appropriate to prevent recurrence of adhesive capsulitis. Individuals whose jobs involve performing heavy manual labor, who operate equipment that causes upper body vibration, and those who must repeatedly lift heavy objects overhead may need to be permanently reassigned to other tasks.

Early in treatment, time must be allowed for multiple physical therapy sessions weekly. Individuals often need breaks during the workday to perform range of motion exercises, and require access to ice packs after exercising. Occasionally, pain medications or muscle relaxants may be prescribed to be taken during work hours. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Risk: Risk factors for adhesive capsulitis include diabetes, stroke, accidents, lung disease, connective tissue disorders, thyroid disease, and heart disease. The condition very rarely appears in people under 40. The risk for injury is related to the limitations in motion.

Capacity: The limitation in range of motion is real. However, the more the individual uses the arm and works through the pain the more range of motion is gained.

Tolerance: This condition is one in which the old saying “no pain, no gain” is very true. The treatment of choice is physical activity. This can be done by formal therapy, home therapy, or by being at work.

Accommodations: Work is good for the shoulder, but the employer may need to limit certain jobs until the range of motion improves.

Source: Medical Disability Advisor



Maximum Medical Improvement

120 to 180 days.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was diagnosis of adhesive capsulitis confirmed?
  • Did x-rays reveal any bony abnormalities?
  • Was shoulder arthrogram or MRI done?
  • Were comorbid conditions identified that could account for delayed recovery?
  • Was a complete neurological exam done?

Regarding treatment:

  • Was physical therapy prescribed to address function, not just to relieve pain?
  • Did individual actively participate in and complete the recommended course of therapy?
  • Did individual improve or worsen during physical therapy?
  • Would individual benefit from additional therapy or a change in therapy?
  • Has individual's need to continue self-directed therapy been accommodated at work?
  • Has individual been compliant with the treatment plan including recommended activity restrictions?
  • Are comorbid conditions also being addressed in the overall treatment plan?
  • If a surgical procedure was required, were there any resulting complications?
  • If recovery from this procedure is not progressing as expected, are there extenuating circumstances?

Regarding prognosis:

  • How long after symptom onset was treatment sought?
  • Did individual receive adequate education in prevention of future overuse problems?
  • Can employer adequately accommodate work restrictions or provide reassignment to lighter tasks?

Source: Medical Disability Advisor



References

Cited

Binder, A. , et al. "Frozen Shoulder: A Long-term Prospective Study." Annals of Rheumatic Diseases 43 (1986): 288-292.

Buchbinder, R., et al., eds. "Arthrographic joint distension with saline and steroid improves function and reduces pain in patients with painful stiff shoulder: results of a randomized double blind, placebo controlled trial." Annals of the Rheumatic Diseases 63 (2004): 302-309.

Buchbinder, R., S. Green, and J. M. Youd. "Corticosteroid Injections for Shoulder Pain." Cochrane Database of Systematic Reviews 1 (2003): CD004016.

Calis, M., et al., eds. "Is intraarticular sodium hyaluronate injection an alternative treatment in patients with adhesive capsulitis." Rheumatology International 26 (2006): 300-305.

Carette, S., et al. "Intraarticular Corticosteroids, Supervised Physiotherapy, or a Combination of the Two in the Treatment of Adhesive Capsulitis of the Shoulder: A Placebo-Controlled Trial." Arthritis and Rheumatism 48 3 (2003): 829-838.

Griggs, S. M., A. Ahn, and A. Green. "Idiopathic Adhesive Capsulitis. A Prospective Functional Outcome Study of Nonoperative Treatment." Journal of Bone and Joint Surgery 82-A 10 (2000): 1398-1407.

Hannafin, J. A., and T. A. Chiaia. "Adhesive Capsulitis. A Treatment Approach." Clinical Orthopaedics and Related Research 372 (2000): 95-109.

Jerosch, J., and W. Aldawoudy. "Chondrolysis of the glenohumeral joint following arthroscopic capsular release for adhesive capsulitis: a case report." Knee Surgery, Sports Traumatology, Arthroscopy 15 (2007): 292-294.

Krabak, Brian J., et al., eds. "Chapter 10 - Adhesive Capsulitis." Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia: Saunders, Elsevier, 2008.

Roy, Andre, et al. "Adhesive Capsulitis in Physical Medicine and Rehabilitation ." eMedicine. Eds. Curtis W. Slipman, et al. 18 Sep. 2012. Medscape. 19 May 2014 <http://emedicine.medscape.com/article/326828-overview>.

Sheridan, M. A. , and J. A. Hannafin. "Upper Extremity: Emphasis on Frozen Shoulder." Orthopedic Clinics of North America 37 4 (2006): 531-539.

Van Der Heijden, G. L., et al. "No Effect of Bipolar Interferential Electrotherapy and Pulsed Ultrasound for Soft Tissue Shoulder Disorders: A Randomized Controlled Trial." Annals of the Rheumatic Diseases 58 9 (1999): 530-540.

Source: Medical Disability Advisor






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