Adhesive Capsulitis Flashcards
Frozen Shoulder:
-GH joint stiffness and lost ROM resulting from a non-contractile element in the shoulder that is not necessarily capsular in nature
-refers to a set of symptoms in the shoulder involving pain and limited motion at the GH joint refers to a variety of pathologies: adhesive capsulitis, subacromial bursitis, calcific tendinitis, rotator cuff pathology
-describes a functional limitation in ROM associated with pain and stiffness
Adhesive Capsulitis:
-involves loss of active and passive motion due to adhesions within the GH joint capsule
-refers to a discrete clinical pathology
-both have the common element of pain and limited motion in the shoulder associated with inert tissues
what is Adhesive Capsulitis:
A painful, significant restriction of AROM and PROM at the shoulder, most frequently in abduction and external rotation
The joint capsule becomes tightened and inflexible
Progresses through 3 stages
Acute stage: joint capsule becomes painfully contracted, with a loss of axillary recess
Subacute stage: capsular fibrosis occurs
Chronic stage: range gradually returns
The superior joint capsule attaches proximal to the greater tuberosity of the humerus and runs medially to the bony rim of the glenoid fossa of the scapula
The inferior joint capsule hangs in a fold or pleat called the “axillary recess”. This fold is stretched out when the humerus is abducted and where adhesions develop
Adhesive Capsulitis Theories
Suggested causes: subacromial bursitis, biceps tendon pathology, suprascapular nerve entrapment leading to muscle dysfunction and small rotator cuff tears
The joint capsule is primarily involved, with secondary involvement of the surrounding structures
Disuse alone is an unlikely cause because it does not develop following paralysis and the subsequent loss of function
Idiopathic frozen shoulder may be due to hyperkyphosis causing an alteration of the scapulohumeral alignment, with consequent stress on the joint capsule
Trigger points in Subscapularis restrict external rotation at the shoulder
Adhesive Capsulitis can be primary or secondary
Primary frozen shoulder is idiopathic
Secondary frozen shoulder results after another pathology such as rotator cuff tears or impingement syndrome
Causes of Adhesive Capsulitis:
Idiopathic factors
Intrinsic musculoskeletal trauma or disorder
Trigger points in Subscapularis
Postural dysfunctions: hyperkyphosis
Disuse following shoulder injury or immobilization
Extrinsic disorders: myocardial infarction (scar from heart surgery), hemiplegia
Systemic diseases: diabetes
Medial Treatment of Adhesive Capsulitis
Analgesics, anti-inflammatories and oral steroids reduce pain symptoms, but have not been shown to change the progression of the condition
Steroids with local anesthetic may be injected into the subacromial space and the joints capsule
Distention arthrography (joint capsule is distended over a series of saline injections) has been shown to rupture adhesions
Manipulation under anesthesia
Symptom Picture:
Acute
freezing phase, first or painful stage
gradual onset of pain
pain is severe at night and patient is unable to lie on the affected side
pain is on the outer aspect of the shoulder and Deltoid insertion
muscle spasm may be present in the rotator cuff muscles
inflammation in the capsule
stiffness is progressive
lasts for 2-9 months
can be unilateral or bilateral
Symptom Picture:
Subacute
frozen phase, second or stiffening phase
severe pain starts to diminish
stiffness becomes the primary complaint, interfering with ADL’s
primary restriction is in the capsular pattern of external rotation, abduction and internal rotation
pain at end ranges
disuse atrophy of Deltoid and rotator cuff muscles may occur
lasts 4-12 months
Symptom Picture:
Chronic
Thawing phase, third or resolution phase
Pain is localized to the lateral arm and continues to diminish
Patient is not awakened at night by pain, as in the acute stage
Motion and function gradually return, full ROM is not always regained
Often said to resolve spontaneously in 2 years, people can remain symptomatic for as long as 5-10 years
Health History Questions
- Has there been a history of injury to the shoulder, including surgery?
- Does the patient have any underlying conditions such as diabetes?
- Where is the pain located?
- Does the pain interrupt sleep?
- What actions are limited?
- Has the frozen shoulder been diagnosed?
- Is the patient doing any other parallel therapies?
- Is the patient taking any medications?
Observations
During the gait cycle, the affected arm is held stiffly and its normal swing is absent
A postural assessment likely reveals a hyperkyphosis and head-forward posture
The affected shoulder is elevated and protracted
Palpation
HT and TP’s are palpated in the affected muscles, especially upper trapezius, levator scapula and the shoulder girdle muscles
shoulder girdle muscles and lateral arm are point tender
in the subacute stage, disuse atrophy and fibrosing are likely present in the muscles of the rotator cuff
Testing-Acute
AF ROM is restricted by pain in external rotation, abduction and internal rotation
A terminal painful arc is present in the available abduction after 70°
The patient may initiate abduction by hiking the shoulder through upper trapezius contraction or by leaning the trunk
PR ROM shows restrictions in external rotation, abduction and internal rotation due to pain
A muscle guarding end feel may be noticed
AR testing for rotator cuff muscles reveals full strength
There may be no pain with resisted movement or pain if there is an associated tendinitis
Testing-Subacute
AF ROM is most restricted in external rotation, abduction and internal rotation
A terminal painful arc is noted in the available abduction after 70°
PR ROM restrictions are in a capsular pattern of external rotation, abduction and internal rotation with a painful, leathery end feel
AR testing reveals little pain on any resisted movement at the shoulder if this is kept in the unrestricted range
Strength may be reduced
