Shoulder pain and mobility deficits- adhesive capsulitis Flashcards
Stage 1 of adhesive capsulitis
1-3 months
sharp pain at end range of motion
Achy pain at rest
Sleep disturbance
Arthroscopic exam- reveals diffuse synovial reaction
Early loss of external rotation- hallmark sign
Stage 2 of adhesive capsulitis
3-9 months
“painful/ freezing” stage
Gradual loss of motion in all directions due to pain
Arthroscopic exam- aggressive synovitis/ angiogenesis and some loss of motion under anasthesia
Stage 3 of adhesive capsulitis
9-15 months
“Frozen stage”
Pain and loss of motion
Synovitis/ angiogenesis lessens but the progressive Capsuloligamentous fibrosis results in loss of axillary fold and ROM when measured under anasthesia
Stage 4 of adhesive capsulitis
15-24 months after onset
“Thawing stage”
Pain begins to resolve but significant stiffness persists
Arthroscopy reveals capsuloligamentous complex fibrosis and receding synovial involvement
What are some subjective complaints of those with adhesive capsulitis
gradual, progressive onset of pain Sleep disturbances at night Pain at end ranges of movement painful and restricted AROM and PROM Functional activity limitations- overhead reaching, behind the back, out to side are increasingly difficult
What is another name for primary adhesive capsulitis
idiopathic- not associated with systemic condition or history of injury
What are the 3 subcategories of secondary adhesive capsulitis
Systemic
Extrinsic
Intrinsic
What are examples of systemic secondary adhesive capsulitis
H/o diabetes and thyroid disease
What are examples of extrinsic secondary adhesive capsulitis
Pathology not directly related to shoulder, yet it results in a painful and stiff shoulder
Examples- CVA, Intra- thoracic conditions (MI, COPD), Intra- abdominal conditions (chronic liver disease), cervical disc disease, distal extremity fracture, or self- imposed immobilization
What are examples of intrinsic secondary adhesive capsulitis
Known pathology of the GH joint
Examples- RTC tendinopathy, biceps tendinopathy, calcific tendinitis, AC or GH joint arthropathy, proximal humeral or scapular fracture
What is the shoulder capsular pattern
ER > ADB > IR
What are some of the characteristics of adhesive capsulitis
Global loss of motion in both directions- Active and passive
ROM loss > 25% in at least 2 planes
Passive ER loss > 50% of uninvolved shoulder
OR < 30 degrees of ER
How would you “rule in” adhesive capsulitis
age 40-65
Gradual onset and progressive worsening of pain/ stiffness
Pain and stiffness limit sleeping, grooming, dressing, reaching
PROM is limited in multiple directions- ER most limited (especially in adduction)
ER/ IR decreases as humerus is abducted towards 90 deg
PROM increase pain at end range
joint glides restricted in all planes
How would you “rule out” adhesive capsulitis
PROM normal
OA seen on XR
Passive ER/ IR increases as humerus is abducted
ULTT reproduces symptoms and shoulder pain can increase/ decrease with altering nerve tension
Pain is reproduced with palpation of peripheral nerve entrapment sites
How would you “rule in” shoulder stability and movement coordination impairments/ dislocation of shoulder joint, or sprain/ strains
< 40 y/o
H/o shoulder dislocation
Excessive GH accessory motions in multiple directions
Apprehension at end range flexion, horizontal abduction, and/or ER
How would you “rule out” shoulder stability and movement coordination impairments/ dislocation of shoulder joint, or sprain/ strains
No h/o dislocation
Presence of global GH motion limitations
No apprehension at end- range shoulder active/ passive motions
How would you “rule in” shoulder pain and muscle power deficits/ rotator cuff syndrome
Symptoms developed, or worsened with repetitive overhead activities or from acute strain, such as fall onto shoulder
Midrange (about 90) of catching sensation/ arc of pain with elevation
Manual resistive tests to RTC, performed at midranges of shoulder flexion and abduction reproduce shoulder pain
RTC muscle weakness
How would you “rule out” shoulder pain and muscle power deficits/ rotator cuff syndrome
Resistive tests are pain-free
Supraspinatus, infraspinatus, and biceps brachii have normal strength
Significant loss of passive motion
What are characteristics of “high irritability” adhesive capsulitis
High levels of pain >7/10
Consistent night or resting pain
High levels of reported disability/ outcome measure
Pain occurs before end ranges of AROM/ PROM
AROM is significantly < PROM
What are characteristics of “moderate irritability” adhesive capsulitis
Pain levels 4-6/10 Intermittent night/ resting pain Moderate disability levels reported/ outcome measure Pain at end range of AROM/ PROM AROM similar to PROM
What are characteristics of “low irritability” adhesive capsulitis
Pain <3/10
No night/ resting pain
Minimal levels of disability reported/ outcome measure
Pain with overpressure at end ranges of PROM
AROM= PROM
What are the intervention strategies for “high irritability” adhesive capsulitis
Heat/ ESTIM for pain modulation
Education on positions of comfort and activity modification to avoid inflammation and pain
Low intensity joint mobs in pain-free accessory range and GH positions
Pain-free PROM or AAROM
What are the intervention strategies for “moderate irritability” adhesive capsulitis
Heat/ ESTIM as needed
Education on progressing activities to gain motion and function without producing inflammation/ pain
Moderate intensity joint mobs, progressing amplitude and duration into tissue resistance without increasing pain/ inflammation
Gentle to moderate stretching exercises, progressing intensity and duration of stretches into tissue resistance without producing post-treatment tissue inflammation and pain
neuro re-ed- to integrate gains in mobility into normal scapulohumeral movement with reaching
What are the intervention strategies for “low irritability” adhesive capsulitis
Education on progression to high demand functional/ recreational activity
Manual- end- range joint mob procedures, high amplitude and long- duration of procedure into resistance
Stretching exercises- increasing in duration and into tissue resistance without increasing pain/ inflammation
Neuro re-ed- to increased gains in mobility into normal scapulohumeral movement during daily functional/ recreational activities
