Shoulder pain and mobility deficits- adhesive capsulitis

Question 1

Stage 1 of adhesive capsulitis

Answer 1

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

Question 2

Stage 2 of adhesive capsulitis

Answer 2

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

Question 3

Stage 3 of adhesive capsulitis

Answer 3

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

Question 4

Stage 4 of adhesive capsulitis

Answer 4

15-24 months after onset
“Thawing stage”
Pain begins to resolve but significant stiffness persists
Arthroscopy reveals capsuloligamentous complex fibrosis and receding synovial involvement

Question 5

What are some subjective complaints of those with adhesive capsulitis

Answer 5

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

Question 6

What is another name for primary adhesive capsulitis

Answer 6

idiopathic- not associated with systemic condition or history of injury

Question 7

What are the 3 subcategories of secondary adhesive capsulitis

Answer 7

Systemic
Extrinsic
Intrinsic

Question 8

What are examples of systemic secondary adhesive capsulitis

Answer 8

H/o diabetes and thyroid disease

Question 9

What are examples of extrinsic secondary adhesive capsulitis

Answer 9

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

Question 10

What are examples of intrinsic secondary adhesive capsulitis

Answer 10

Known pathology of the GH joint
Examples- RTC tendinopathy, biceps tendinopathy, calcific tendinitis, AC or GH joint arthropathy, proximal humeral or scapular fracture

Question 11

What is the shoulder capsular pattern

Answer 11

ER > ADB > IR

Question 12

What are some of the characteristics of adhesive capsulitis

Answer 12

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

Question 13

How would you “rule in” adhesive capsulitis

Answer 13

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

Question 14

How would you “rule out” adhesive capsulitis

Answer 14

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

Question 15

How would you “rule in” shoulder stability and movement coordination impairments/ dislocation of shoulder joint, or sprain/ strains

Answer 15

< 40 y/o
H/o shoulder dislocation
Excessive GH accessory motions in multiple directions
Apprehension at end range flexion, horizontal abduction, and/or ER

Question 16

How would you “rule out” shoulder stability and movement coordination impairments/ dislocation of shoulder joint, or sprain/ strains

Answer 16

No h/o dislocation
Presence of global GH motion limitations
No apprehension at end- range shoulder active/ passive motions

Question 17

How would you “rule in” shoulder pain and muscle power deficits/ rotator cuff syndrome

Answer 17

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

Question 18

How would you “rule out” shoulder pain and muscle power deficits/ rotator cuff syndrome

Answer 18

Resistive tests are pain-free
Supraspinatus, infraspinatus, and biceps brachii have normal strength
Significant loss of passive motion

Question 19

What are characteristics of “high irritability” adhesive capsulitis

Answer 19

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

Question 20

What are characteristics of “moderate irritability” adhesive capsulitis

Answer 20

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

Question 21

What are characteristics of “low irritability” adhesive capsulitis

Answer 21

Pain <3/10
No night/ resting pain
Minimal levels of disability reported/ outcome measure
Pain with overpressure at end ranges of PROM
AROM= PROM

Question 22

What are the intervention strategies for “high irritability” adhesive capsulitis

Answer 22

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

Question 23

What are the intervention strategies for “moderate irritability” adhesive capsulitis

Answer 23

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

Question 24

What are the intervention strategies for “low irritability” adhesive capsulitis

Answer 24

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

Question 25

What functional measures are recommended for adhesive capsulitis

Answer 25

ASES
DASH
SPADI

Question 26

What are the recommendations for corticosteroid injections for adhesive capsulitis

Answer 26

A evidence
Injections combined with shoulder mobility and stretching are more effective in providing short- term pain relief and improving function compared to shoulder mobility and stretching alone

Question 27

What recommendations are made for patient education and adhesive capsulitis

Answer 27

B evidence
Should utilize education that:
1. Describes the natural course of the disease
2. Promotes activity modification to encourage functional, pain-free ROM
3. Matches the intensity of stretching to patients level of irritability

Question 28

What recommendations are made for modalities and adhesive capsulitis

Answer 28

C evidence

Short wave diathermy, U/S, ESTIM combined with mobility and stretching to reduce pain and improve shoulder ROM

Question 29

What recommendations can be made about joint mobilizations for adhesive capsulitis

Answer 29

C evidence

May utilize joint mobilizations of GH joint to reduce pain and increase motion and function

Question 30

What recommendations can be made about translational manipulation for adhesive capsulitis

Answer 30

C evidence

May utilize MUI of GH joint if they arent responding conservatively

Question 31

What recommendations can be made about stretching exercises for adhesive capsulitis

Answer 31

B evidence

Should instruct patients for stretching exercises- intensity determined by irritability level