Adhesive Capsulitis (Frozen
Shoulder)
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 disorder
diagnostic criteria
A patient meets the criteria if painful, restricted active and passive
glenohumeral and scapulothoracic motion occurs for at least 1 month.
Types of frozen shoulder
Primary:
Patients with primary frozen shoulder have no significant findings in the
history, clinical examination, or radiographic evaluation to explain their
motion loss and pain.
Secondary:
secondary FSS describe an event that preceded the onset of shoulder symptoms,
such as the following:
Upper extremity trauma (eg, shoulder surgery, rotator cuff tear, proximal
humerus facture)
Immobilization (eg, cardiothoracic surgery, neurosurgery)
Metabolic/endocrine (eg, thyroid disease, diabetes mellitus, autoimmune
disease, hyperlipidemia)
Neurologic (eg, stroke, Parkinson disease)
Cardiac disease (eg, ischemic heart disease, hypertension)
Drugs (eg, protease inhibitors, antiretrovirals, immunizations,
fluoroquinolones)
Malignancy
Pathophysiology
Repeated strain
Inflammation
Fibrosis
Capsular thickening
Signs and symptoms
Slow-onset shoulder pain
Localized discomfort near the deltoid insertion
Inability to sleep on the affected side
Restricted glenohumeral elevation and external rotation
A normal radiologic appearance
limited abduction from 45-135
Stages of frozen shoulder
freezing (painful)
pain is worst at night
pain increases with movement
last 3 to 6 months
frozen (stiffening)
ROM limited
6 to 12 months
Thawing(recovery)
12 to 18 months
Diagnosis
Pain and stiffness: Gradual onset of pain and stiffness in the shoulder.
Limited range of motion: Difficulty moving the shoulder in all directions.
Absence of other causes: Ruling out other conditions like rotator cuff tears or arthritis.
In rotator cuff tear the passive range of motion is preserve
Clinical Scenario of Frozen Shoulder:
Patient: A 55-year-old female with a history of diabetes presents with gradual onset of
shoulder pain and stiffness over the past 3 months. The pain is worse at night, and she has
difficulty reaching behind her back and sleeping on the affected side.
Physical Therapy Assessment and Examination:
Subjective:
Pain: Constant dull ache in the shoulder, worse at night.
Onset: Gradual onset over 3 months.
Location: Diffuse shoulder pain, radiating to the upper arm.
Aggravating factors: Movement, sleeping on the affected side.
Relieving factors: Rest, pain medication.
Functional limitations: Difficulty with activities of daily living (ADLs) like dressing,
grooming, and reaching overhead.
Objective:
Observation: Posture appears normal, no obvious signs of inflammation.
Palpation: Tenderness over the shoulder joint capsule.
Range of Motion (ROM): Significant limitation in all directions, particularly external
rotation.
Strength: Mild weakness in shoulder muscles due to disuse.
Special tests: Positive impingement signs, limited internal and external rotation.
Diagnosis: Frozen shoulder (adhesive capsulitis)
Treatment Plan:
Phase 1: Freezing Stage (Pain Management)
Modalities: Ice packs, heat packs, ultrasound therapy.
Manual therapy: Gentle joint mobilization, soft tissue massage.
Therapeutic exercises: Pendulum exercises, Codman's exercises, gentle stretching
within pain-free range.
Home exercise program: Stretching exercises to maintain ROM, pain management
techniques.
Phase 2: Frozen Stage (Regaining ROM)
Manual therapy: Joint mobilization, stretching techniques (e.g., posterior capsule
stretch).
Therapeutic exercises: Progressive stretching exercises, gentle strengthening
exercises.
Home exercise program: Regular stretching and strengthening exercises.
Phase 3: Thawing Stage (Restoring Function)
Manual therapy: Continuation of joint mobilization, stretching techniques.
Therapeutic exercises: Progressive strengthening exercises, functional exercises
(e.g., reaching, overhead activities).
Home exercise program: Regular stretching and strengthening exercises, functional
activities.
Additional Considerations:
Education: Patient education on the condition, treatment goals, and self-
management techniques.
Pain management: Medications (e.g., NSAIDs, corticosteroids) as needed.
Referral to other specialists: If conservative treatment fails, referral to a
rheumatologist or orthopedic surgeon for further evaluation and management.
Capsular pattern of frozen shoulder
External Rotation: This is the most limited movement.
Abduction: The second most limited movement.
Internal Rotation: The least limited movement.
Flexion
CODMAN’S EXERCISES
Pendulum, Circular
Shoulder Forward Elevation (Assisted)
Supported Shoulder Rotation (Assisted
Shoulder Internal Rotation (Assisted)
Walk Up Exercise (Active)
Shoulder Forward Elevation (Active)
Shoulder Abduction (Active)
Shoulder Extension (Isometric)
Shoulder External Rotation (Isometric)
Shoulder Internal Rotation (Isometric)
Shoulder Adduction (Isometric)
Shoulder Abduction (Isometric)
Shoulder Internal Rotation (Strengthening)
Shoulder External Rotation (Strengthening)
