Adhesive Capsulitis of Shoulder

© Reed Group

Risk: Age increases risk, with most cases of FS occurring during the fifth and sixth decades of life; average age of onset is 52 years in women and 55 years in men (Roy). The condition occurs more frequently in women than in men (M-F ratio is 1.4:1) (Roy).

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).

History: The individual usually reports a gradual onset that begins 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. Usually moving the arm away from the body (abduction) and outward (external) rotation are 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° of external rotation and less than 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. However, in primary adhesive capsulitis, x-rays usually are normal and are not definitive for diagnosis of the condition. X-rays of the cervical spine and/or electromyography (EMG) may be needed to evaluate neurological function, especially 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 an MRI scan increased blood flow.

The rehabilitation for adhesive capsulitis of the shoulder will vary depending on the phase at which the patient presents for treatment. However, treatment involves active exercise in all three phases.

Phase 1: (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 instruct in 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. Focus should be on reducing pain and preventing loss of motion.

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

Phase 3: (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 scapula musculature. Continue to emphasize exercises that promote normal glenohumeral movement (Hannafin).

Past research does not support the benefit of ultrasound, electrical stimulation (Van Der Heijden), heat, ice or iontophoresis for the treatment of adhesive capsulitis. Modalities may be beneficial for palliative relief of symptoms. Home exercise programs are critical, must be performed daily and should reflect the exercise regimen prescribed during rehabilitation (Hannafin). Intra-articular corticosteroid injections combined with physical therapy have been shown to be beneficial for the short term; however the effect was not well maintained over a 12 month period (Buchbinder; Carette).

Residual pain / limitations: Although a large degree of variability is discussed in the literature, up to 40% of those with adhesive capsulitis report resumed normal function despite some residual pain or limitations of movement (Griggs).