COLLEGE OF PHYSICAL AND RESPIRATORY THERAPY

S.Y. 2016-2017

SEMINAR 1

MEDICAL BACKGROUND ON
ADHESIVE CAPSULITIS

SUBMITTED TO:
Bernardo Tayaban Jr., PTRP
Maverick Kaypee Colet, PTRP

SUBMITTED BY:
Gurtiza, Joanna Eden A.

I.

Introduction
The first reported description of frozen shoulder was made by Duplay in the late
1800s.They used the label scapulohumeral periarthritis to describe a broad
spectrum of pathologies of the shoulder that resulted to pain, stiffness, and
dysfunction. This label served as an umbrella term that encompassed disorders
such as rotator cuff tendonitis ad tears, biceps tendonitis and tears, calcific
deposits, AC arthritis, and other painful shoulder syndromes.

The term frozen shoulder was later coined in 1934 by Codman, who
characterized the condition as involving a slow onset, pain near the deltoid
insertion, inability to sleep on the affected side, painful and restricted elevation
and lateral rotation, and a normal radiological appearance.
Codman described the condition as difficult to define, difficult to treat and difficult
to explain from the point of view of pathology.
Lundberg introduced the terms primary and secondary further describe frozen
shoulders in 1969. Primary frozen shoulder, are those with idiopathic onset,
whereas secondary frozen shoulders occur following trauma and or
immobilization. Secondary frozen shoulders have been further classified into
intrinsic, extrinsic, and systemic categories by Zuckeman and Rokito.
Naviaser describes adhesive capsulitis as a distinct entity with four identifiable
stages that are arthroscopically distinct:
Stage 1 (painful stage)
- Shoulder motion is restricted little if at all during this stage.
- Arthroscopy shows an erythematous fibrinous pannus over the
synovium, primarily around the dependent fold.
- The articular cartilage is normal in condition
- Duration of symptoms: 0-3 months
Stage 2 (freezing stage)
- Characterized by pain with associated loss of motion in all planes
- Arthroscopically, the synovium appears red, thickened, and
inflamed.
- Adhesions across the dependent fold can be seen.
- There is loss of the space between the humeral head and glenoid
as well as between the humeral head and biceps tendon.
- Duration of symptoms:3-9 months
Stage 3 (frozen stage)
- Characterized by the transition from inflammatory synovitis to
chronic fibrosis and by markedly decreased size of the
dependent fold.
- There is complete obliteration of the space between the humeral
head and biceps tendon.
- Duration of symptoms:9-15 months
Stage 4 (thrawing stage)
- There is no longer synovitis present
- The dependent fold has become severely contracted by this
stage
- Shoulder motion s severely limited.
- Duration of symptoms:15-24 months

II.

Definition of Terms

III.
Epidemiology
Prevalence of frozen shoulder
is 2% to 5% in the general population
- 10%-20% in patient with diabetes.
Sex
Females are more commonly affected than males.
Age
- Most frequently seen in individuals between 40-60 years old.
Work
- Sedentary workers are commonly affected than laborers.
IV.

Anatomy, Physiology, Kinesiology of Muscles

Shoulder region is a complex of :
20 muscles
three bony articulations,
three soft tissue moving surfaces (functional joints) that permit the greatest mobility of
any joint area found in the body.
The primary purpose of the shoulder is to put the hand in a position for function.

BONES

Manubrium
Clavicle
-

The manubrium (L. manubrium, handle) is the most cephalic aspect of the
sternum and the site at which the left and right clavicles secure the upper
extremities to the axial skeleton.
From a superior to inferior view, the clavicle (L. clavicula, diminutive of
clavus, key) is S-shaped, like a crank, with its forward convexity at its sternal
end to clear the brachial plexus and upper extremity vascular bundle and its
forward concavity at the humeral end.

Scapula
The scapula (L. scapula, shoulder blade) is a flat, triangular-shaped bone with three
sides and three angles that sits against the posterior thorax.
It has a dual function:
to provide a place for muscles controlling the glenohumeral joint to
venture from and to provide a stable base from which the
glenohumeral joint can function.
- It works intimately with the clavicle to provide the glenohumeral joint
more motion so the hand can be placed in more positions.]
Parts of scapula
inferior angle of the scapula
- where the vertebral border and lateral border meet
glenoid fossa
- is the superior lateral aspect of the scapula that forms the
concave portion of the glenohumeral joint.
superior border
is difficult to palpate but lies essentially parallel to the spine of
the scapula.
scapular spine
lies on the posterior scapula and divides the scapula into two
fossae, the supraspinatus fossa and the infraspinatus fossa.
supraspinatus fossa
- above the spine
infraspinatus fossa
- below the spine
acromion process
- sits over the glenohumeral joint to protect it from overhead
forces applied down toward the shoulder
coracoid process.
- This process sits below the clavicle and is medial to the glenoid
fossa.
- It protrudes anteriorly from the scapula and is a site of multiple
ligament and muscle attachments.
Humerus
Parts of humerus
head of the humerus
- is the convex segment that interfaces with the concave glenoid
fossa to form the glenohumeral joint.

greater tubercle
- sits lateral to the lesser tubercle and is a large round
protuberance.
lesser tubercle
- is smaller and sharper and lies more medially.
neck of the humerus
is a circumferential area on the proximal humerus.

JOINTS

the clavicle articulates with the manubrium of the sternum at the sternoclavicular
(SC) joint;
the clavicle and the scapula join at the acromioclavicular (AC) joint; and
the humerus articulates with the scapula at the glenohumeral (GH) joint.
During movements of the shoulder complex, the scapula also slides on the thorax;
this connection is the scapulothoracic (ST) joint.

GLENOHUMERAL JOINT

the term shoulder joint refers to the glenohumeral (GH) joint.

BONES:

The GH joint is located between the scapula and the humerus.

More specifically, it is located between the glenoid fossa of the scapula and the head of
the humerus.
Joint structure classification:
o Synovial joint
o Subtype: Ball-and-socket joint
Joint function classification:
o Diarthrotic
o Subtype: Triaxial
MAJOR MOTIONS ALLOWED:

The GH joint allows flexion and extension

- in the sagittal plane around a mediolateral axis
The GH joint allows abduction and adduction
in the frontal plane around an anteroposterior axis
The GH joint allows lateral rotation and medial rotation
- in the transverse plane around a vertical axis

Reverse Actions:

The muscles of the GH joint are generally considered to move the more distal
arm on the more proximal scapula.
However, the scapula can move at the GH joint relative to the humerus; this is
especially true if the arm is fixed such as when the hand is gripping an
immovable objectin other words, during a closedchain activity
The major reverse actions of the scapula at the GH joint are
- upward rotation and downward rotation.

MAJOR LIGAMENTS OF THE GLENOHUMERAL JOINT

Fibrous joint capsule

Superior glenohumeral (GH) ligament
Middle GH ligament
Inferior GH ligament
Coracohumeral ligament

Fibrous Joint Capsule:

The capsule of the GH joint is extremely lax and permits a great deal of motion.
The GH joint capsule is so lax that if the musculature of the shoulder joint is completely
relaxed, the head of the humerus can be moved away from the glenoid fossa 1 to 2
inches (2.5 to 5.0 cm).
The GH joint capsule is thickened and strengthened by glenohumeral (GH) ligaments.
o Three GH ligaments exist:
- (1) the superior glenohumeral ligament
- (2) the middle glenohumeral ligament
- (3) the inferior glenohumeral ligament

Superior, Middle, and Inferior Glenohumeral Ligaments:

These ligaments are thickenings of the anterior and inferior joint capsule.
Function:
- They prevent dislocation of the humeral head anteriorly and inferiorly.
- As a group, these three ligaments also limit the extremes of all GH joint
motions.
- There is a small region of the anterior GH joint capsule called the foramen
of Weitbrecht that is located between the superior and middle
glenohumeral (GH) ligaments.
- The foramen of Weitbrecht is a relatively weak region where the majority
of shoulder dislocations occur.

Coracohumeral Ligament:

Location:
- The coracohumeral ligament is located between the coracoid process of
the scapula and the greater tubercle of the humerus.
Function:
- It prevents dislocation of the humeral head anteriorly and inferiorly and
limits extremes of flexion, extension, and lateral rotation.

CLOSED-PACKED POSITION OF THE GLENOHUMERAL JOINT:

Lateral rotation and abduction
MAJOR MUSCLES OF THE GLENOHUMERAL JOINT:
Flexors cross the GH joint anteriorly and are the:
- anterior deltoid, pectoralis major, coracobrachialis, and biceps brachii.
Extensors cross posteriorly and are the:
- posterior deltoid, latissimus dorsi, teres major, and long head of the
triceps brachii.
Abductors cross superiorly (over the top of the joint) and are the:
- deltoid and supraspinatus.
Adductors cross below the center of the joint from the trunk to the arm and are
located:
- both anteriorly and posteriorly.
- Some adductors are the pectoralis major, latissimus dorsi, and teres
major.
Lateral rotators such as:
the posterior deltoid, infraspinatus, and teres minor cross the GH joint
and wrap around the humerus, ultimately attaching to the posterior
side of the humerus.
Medial rotators such as:
the anterior deltoid, latissimus dorsi, teres major, and subscapularis
cross the GH joint and wrap around the humerus, ultimately attaching
to the anterior side of the humerus.

MISCELLANEOUS:

A cartilaginous glenoid labrum

forms a lip around the glenoid
- The cartilaginous glenoid labrum is analogous to the acetabular labrum of the
hip joint.
- The glenoid labrum deepens the glenoid fossa and cushions the joint.
Bursa
known as the subacromial bursa
- is located between the acromion process of the scapula and the rotator cuff
tendon
- The subacromial bursa reduces friction between the rotator cuff tendon
inferiorly and the acromion process and deltoid muscle superiorly.
- The subacromial bursa is also known as the subdeltoid bursa because it
extends inferiorly/distally and is also located between the deltoid muscle and
the rotator cuff tendon.
- This bursa is the famous shoulder joint bursa that is so often blamed for soft
tissue pain of the shoulder joint.
Coracoacromial arch
- The roof of the GH joint is formed by the coracoacromial arch.
The coracoacromial arch is composed of the:
coracoacromial ligament
- acromion process of the scapula
coracoacromial ligament
- is a bit unusual in that it attaches to two landmarks of the same bone
the coracoid process of the scapula to the acromion process of the
scapula. Most often, musculoskeletal ligaments run from one bone to a
different bone.
The coracoacromial arch functions:
- to protect the superior structures of the GH joint.

SCAPULOCOSTAL (ScC) JOINT

The scapulocostal (ScC) joint is also known as the scapulothoracic joint.

BONES:
The scapula and the ribcage
- More specifically, the anterior surface of the scapula and the posterior
surface of the ribcage
Joint type: Functional joint
The ScC joint is unusual in that it is not an anatomic joint because no actual
union of the scapula and the ribcage is formed by connective tissue. However,
because it behaves as a joint does in that movement of the scapula relative to
the ribcage occurs, it is considered to be a functional joint.
MAJOR MOTIONS ALLOWED:
Major motions allowed are as follows
Of all the scapular actions possible:
o only elevation/ depression and protraction/retraction can be primary
movements, meaning that each one of these movements can be
created separately by itself.
The other scapular actions are secondary in that they must occur secondary to
an action of the arm at the glenohumeral (GH) joint.
o Protraction and retraction (nonaxial movements) of the scapula
o Elevation and depression (nonaxial movements) of the scapula
o Upward rotation and downward rotation (axial movements) of the
scapula
o Note: Upward rotation and downward rotation of the scapula occur
within the frontal plane around an anteroposterior axis (these are
approximations of the plane and axis, because the scapula is not
situated perfectly within the frontal plane because of the shape of the
posterior ribcage wall).
Accessory Movements:
Accessory movements include the following:
Lateral tilt and medial tilt (axial movements) of the scapula
Upward tilt and downward tilt (axial movements) of the scapula
Lateral tilt of the scapula is usually referred to in lay terms as winging of
the scapula.
Reverse Actions:
The ribcage (i.e., the trunk) can move relative to the scapula.
One example of a reverse action at the scapulocostal (ScC) joint in which the
ribcage (i.e., the trunk) moves relative to the scapula is when :
- push-ups are done.
- The objective of a push-up is to exercise muscles by pushing the body
up and away from the floor. At the very end of a push-up, after the upper

extremities are perfectly vertical, a little more elevation of the trunk away
from the floor is possible.
This motion is caused by protractors of the scapula such as the serratus
anterior contracting and pulling the trunk (which is more mobile) up
toward the scapulae (which are fixed, because the hands are planted
firmly on the floor).

MAJOR MUSCLES OF THE SCAPULOCOSTAL JOINT:

Elevators of the scapula;
- attach from the scapula to a more superior structure
- examples are the upper trapezius, levator scapulae, and rhomboids.
Depressors
attach from the scapula to a more inferior structure
examples are the lower trapezius and the pectoralis minor.
Protractors
- attach from the scapula to a more anterior structure
examples are the serratus anterior and the pectoralis minor.
Retractors
attach from the scapula to a more midline structure posteriorly;
examples are the middle trapezius and the rhomboids.
Upward rotators of the scapula include the:
- serratus anterior and the upper and lower trapezius.
Downward rotators
include the pectoralis minor, rhomboids, and levator scapulae.
MISCELLANEOUS:
The scapula articulates with the ribcage at the ScC joint
the clavicle at the AC joint
the humerus at the GH joint.
Therefore the scapula can move relative to any of these structures, and the
motion could be described as occurring at the joint located between the scapula
and any one of these three bones.
STERNOCLAVICULAR (SC) JOINT
The sternoclavicular joint is also known as the SC joint.
BONES:
The manubrium of the sternum and the medial end of the clavicle
Joint structure classification: Synovial joint
o Subtype: Saddle
Joint function classification: Diarthrotic
o Subtype: Biaxial
o
MAJOR MOTIONS ALLOWED:
Major motions allowed are as follows :
Protraction and retraction of the clavicle (axial movements):
- These motions occur within the transverse plane around a vertical axis.
Elevation and depression of the clavicle (axial movements):

These motions occur within the frontal plane around an anteroposterior

axis.
Upward rotation and downward rotation of the clavicle (axial movements):
These motions occur within the sagittal plane around a mediolateral axis (this axis
runs through the length of the bone).

MAJOR LIGAMENTS OF THE STERNOCLAVICULAR JOINT:

Fibrous capsule
Anterior SC ligament
Posterior SC ligament
Interclavicular ligament
Costoclavicular ligament
Fibrous Joint Capsule:
- The SC joint capsule is fairly strong and is also reinforced by
sternoclavicular ligaments.
Anterior and Posterior Sternoclavicular Ligaments:
Two SC ligaments exist:
(1) the anterior sternoclavicular ligament and
(2) the posterior sternoclavicular ligament.
The sternoclavicular ligaments are reinforcements of the joint capsule found
anteriorly and posteriorly.
Interclavicular Ligament:
The interclavicular ligament spans from one clavicle to the other clavicle.
Costoclavicular Ligament:
- The costoclavicular ligament runs from the first rib to the clavicle.
- The costoclavicular ligament has anterior and posterior fibers.
The costoclavicular ligament limits all motions of the clavicle except
depression.

CLOSED-PACKED POSITION OF THE STERNOCLAVICULAR JOINT:

Full upward rotation of the clavicle

MISCELLANEOUS:
A fibrocartilaginous articular disc is located within the SC joint.
This disc helps to improve the congruence of the joint surfaces and also to absorb
shock.
ACROMIOCLAVICULAR (AC) JOINT
The acromioclavicular joint is also known as the AC joint.
BONES:
The acromion process of the scapula and the lateral (i.e., distal) end of the
clavicle
Joint structure classification: Synovial joint
o Subtype: Plane joint
Joint function classification: Diarthrotic
o Subtype: Nonaxial
MOTIONS ALLOWED:
Upward rotation and downward rotation of the scapula (axial movements) relative
to the clavicle
Without motion at the AC joint, the scapula and clavicle (i.e., the shoulder girdle)
would be forced to always move as one fixed unit.
The AC joint allows for independent motion between the scapula and clavicle.
The major actions at the AC joint are movements of the scapula relative to the
clavicle.
These motions of the scapula allow greater overall motion of the shoulder joint
complex, which translates into the ability to move and place the hand throughout
a greater range of motion
Accessory Actions:
Lateral tilt and medial tilt of the scapula (axial movements)
Upward tilt and downward tilt of the scapula (axial movements)
Reverse Actions:
The clavicle can move relative to the scapula at the AC joint.
MAJOR LIGAMENTS OF THE ACROMIOCLAVICULAR JOINT:

Fibrous capsule
Acromioclavicular (AC) ligament
Coracoclavicular ligament (trapezoid and conoid)

Fibrous Joint Capsule:

- The joint capsule is weak and is reinforced by the acromioclavicular ligament
Acromioclavicular Ligament:
- The AC ligament is a reinforcement of the AC joint capsule.
- The AC ligament is often divided into:
superior acromioclavicular ligament and
inferior acromioclavicular ligament, which are reinforcements of the
AC joint capsule found superiorly and inferiorly.

Coracoclavicular Ligament:
- The coracoclavicular ligament has two parts:
- (1) the trapezoid ligament and
- (2) the conoid ligament.
Location:
- The coracoclavicular ligament attaches from the coracoid
process of the scapula to the clavicle.
- More specifically, it attaches to the lateral (i.e., distal) end of the
clavicle on the inferior surface.
- The trapezoid ligament
- is more anterior in location and attaches from the superior
surface of the coracoid process to the trapezoid line of the
clavicle (on the inferior surface at the lateral end of the
clavicle).
- The conoid ligament
- is more posterior in location and attaches from the proximal
base of the coracoid process of the scapula to the conoid
tubercle of the clavicle (on the inferior surface at the lateral
end of the clavicle).
- Function:
- The coracoclavicular ligament does not directly cross the AC joint itself, but it
does cross from the scapula to the clavicle and therefore adds stability to the
AC joint.

CLOSED-PACKED POSITION OF THE ACROMIOCLAVICULAR JOINT:

Full upward rotation of the scapula
MISCELLANEOUS:
Often a fibrocartilaginous disc is located within the AC joint.
The AC joint is very susceptible to injury (e.g., a fall on an outstretched arm) and
degeneration.

MUSCLES FROM TRUNK TO SHOULDER GIRDLE

Serratus anterior

The most important muscle of the shoulder girdle.

Without it, arm cannot be raised overhead.
Proximal attachments:
- By nine muscular slips from the anterolateral aspect of the thorax, from
the first to ninth ribs. saw muscle
Distal attachment:
- Medial border of the scapula.
Innervation:
- Long thoracic nerve (C5-C7)
Anatomic actions:
- Abduction and upward rotation of the scapula.

Trapezius

Superficial muscle of the neck and upper back.

Proximal attachments:
- Occipital bone, ligamentum nuchae, and spinous processes from C7-T12.
Distal attachment:
- Acromial end of the clavicle, the acromion, and the spine of the scapula.
Innervation:
- Spinal accessory nerve (C3-C4)
Anatomic actions:
- Upper trapezius:
Elevation and upward rotation of the scapula
Extension, lateral flexion, and contralateral rotation of the neck
- Lower trapezius
Upward rotation, adduction, and depression of the scapula
- Middle trapezius
Upward rotation and adduction of the scapula

Rhomboids major and minor

Connects the scapula with the vertebral column, lie underneath the trapezius.
Upper portion: rhomboids minor
Lower portion: rhomboids major
Proximal attachments:
- Ligamentum nuchae and spinous processes of the lowest two cervical
and the upper four thoracic vertebrae
Distal attachment:
- Medial border of the scapula
Innervation:
- Dorsal scapular nerve (C4-C5)
Anatomic actions:
- Downward rotation, adduction, and elevation of the scapula.

Pectoralis minor

Located anteriorly on the upper chest.

Proximal attachments:
- By four tendomuscular slips from the second to fifth ribs.
Distal attachment:
- Coracoid process of the scapula
Innervation:
- Medial pectoral nerve (C7-T1)
Anatomic actions:
- Depression and ventral tilt of the scapula
- Elevation of ribs 2-5

Levator Scapulae

Proximal attachment:
- transverse processes of the upper cervical vertebrae
Distal attachment:
- medial border of the scapula, above the spine, near the superior angle
Innervation:
- Dorsal Scapular Nerve
Action:
- Elevation and downward rotation of the scapula
- Lateral flexion and ipsilateral rotation of the cervical spine

MUSCLES FROM SHOULDER GIRDLE TO HUMERUS

Deltoid

covers the glenohumeral joint on all sides except the axilla

Proximal attachment:
- acromial end of the clavicle, the acromion process, and the spine of
scapula
Distal attachment:
- deltoid tuberosity
Innervation:
- Axillary Nerve
Action:
Abduction of the glenohumeral joint
- Anterior deltoid :
flexion and horizontal adduction of the glenohumeral joint
- Posterior deltoid :
extension and horizontal abduction of the glenohumeral joint

Supraspinatus

Muscle located above the spine of the scapula

Proximal attachment:
- supraspinous fossa of the scapula
Distal attachment:
upper most facet of the greater tubercle of the humerus
Innervation:

Suprascapular Nerve

Infraspinatus and Teres Minor

Described together because they are closely related in location and action
Proximal attachment:
Infraspinatus infraspinous fossa
- Teres Minor Lateral border of the scapula
Distal attachment:
- Infraspinatus greater tubercle of the middle facet
- Teres Minor greater tubercle of the lower facet
Innervation:
- Infraspinatus Suprascapular Nerve
- Teres Minor Axillary Nerve
Action:
External rotation and abduction of the glenohumeral joint

Teres Major

Located at the axillary border of the scapula, distal to the teres minor
Proximal attachment:
Inferior angle of the scapula
Distal attachment:
- crest of lesser tubercle of the humerus
Innervation:
- Subscapular nerve
Action:
- Flexion and adduction of the glenohumeral joint

Coracobrachialis

Proximal attachment:
Coracoid process of the scapula
Distal attachment:
- medial surface of the humerus
Innervation:
- Musculocutaneous Nerve
Action:
- Flexion and adduction of the glenohumeral joint

Biceps brachii and Triceps brachii

The two head of the biceps and the long head of the triceps cross the shoulder joint and
there for act on it
Attachment:
heads of the biceps attach to the supraglenoid tubercle and to the
coracoids process
- Triceps attaches to the infraglenoid tubercle
Action:
Biceps flexor and abductor of the glenohumeral joint
Triceps extensor and adductor of the glenohumeral joint

MUSCLE FROM TRUNK TO HUMERUS

Latissimus Dorsi

Broadest muscle of the back

Proximal attachment:
spinous process of thoracic vertebrae from T6 downward, dorsolumbar
fascia
Distal attachment:
by a tendon that courses in the axilla and attaches to the crest of lesser
tubercle of the humerus
Innervation:
- Thoracodorsal nerve
Action:
Internal rotation, extension and adduction of the glenohumeral joint
- Scapular depression
- Elevation of pelvis

Pectoralis Major

Large muscle of the chest

Proximal attachment:
clavicle, sternum, and costal cartilages of the 2nd and 7th ribs and the
aponeurosis over the abdominal muscle
Distal attachment:
crest of greater tuberosity of the humerus
Innervation:
Medial and lateral pectoral nerve
Action:
Adduction and internal rotation of the glenohumeral joint.

SCAPULOHUMERAL RHYTHM

V.

scapular rotation to facilitate shoulder movements (abduction & flexion)

1st 30 of abduction or 45 of flexion -- scapula moves to a position of

stability on thorax

beyond this initial range -- a 5:4 ratio of glenohumeral to scapular movements

for total ROM have a 2:1 ratio (e.g. 180 of abduction have 120 of
glenohumeral mvmt and 60 of scapular mvmt.

Etiology

The causes of frozen shoulder are not fully understood. There is no clear connection to
arm dominance or occupation. A few factors may put you more at risk for developing frozen
shoulder.
The causes for frozen shoulder could be:

a) Intrinsic, e.g. associated with shoulder disorder or trauma

(1) Stiffness following shoulder surgery
(2) Rotator cuff pathology
(3) Impingement syndrome
(4) Glenohumeral osteoarthritis
(5) Acromioclavicular joint osteoarthritis
(6) Posterior labral tears
(7) Biceps pathology
b) Extrinsic, e.g. associated with condition external to the shoulder
(1) Proximal humeral fracture
(2) Cervical spine disease
(3) Cardiac disease
(4) Neurological conditions
(5) Non-shoulder surgery
c) Systemic
(1) Diabetes mellitus
(2) Thyroid disease

Primary: Here the exact cause is not known and it could be idiopathic.
Secondary: According to Lumberg, the secondary causes could be:
- Shoulder causes: Problems directly related to shoulder joint which
can give rise to frozen shoulder are tendonitis of rotator cuff, bicipital
tendinitis, fractures and dislocations around the shoulder, etc.
- Nonshoulder causes: problems not related to shoulder joint like
diabetes, cardiovascular diseases with referred pain to the shoulder,
which keeps the joint immobile, reflex sympathetic dystrophy, frozen
hand shoulder syndrome, a complication of Colles fracture, can lead
to frozen shoulder. The reason could be prolonged immobilization of
the shoulder joint due to referred paun, et

VI.

Pathophysiology/Mechanism of Injury/Pathology

Secondary (Less

Primary
(Idiopathic):Unknown
v
etiology, but
associated with
autoimmune disorders
(diabetes mellitus,
thyroid disease)

In select populations
(age 40-60, women >
men), the glenohumeral
joint capsule ligaments
become inflamed,
usually in one (nondominant) shoulder.

Over time, active

shoulder joint
inflammation as
post-inflammatory
healing (i.e. local
connective tissue

Months later, active

shoulder joint
inflammation will stop,
but post-inflammatory
tissue healing creates
abundant scar tissue.

Years later, scar tissue

in the joint space and
capsule will eventually
break down itself, to be
replaced by healthy,
flexible ligaments.

Pathophysiology

Prolonged shoulder
injury (i.e. post
shoulder surgery,
rotator cuff tear,
humeral head fracture).

Cytokinesis and
other inflammatory
molecules are
released.

Prolonged shoulder
immobility (i.e. after a
stroke that cause
hemiplegia, or during
recovery after

Triggers local
nociceptors (pain
receptor
neurons).

Less inflammatory
molecules are released in
the shoulder.
Fibrotic scar tissue begin
to accumulate within the
glenohumeral at joint
space.
No inflammatory
molecules are released.

More scar tissue

accumulates in the
glenohumeral joint space,
as well as thickening and
contracting the joint

Joint space and joint

capsule mobility are
gradually restored.

Mechanis
m

Signs/symptom/lab
finding

Less activation
of local
nociceptors.

Shoulder Pain:
Diffuse throughout
shoulder Severe,
worse at night
Disabling (i.e. cant
sleep on painful

Shoulder

Volume of space in
the joint capsule
declines

Shoulder
stiffness
(progressive
restriction of
shoulder

No activation of
local nociceptor.

No shoulder
pain

Severe in
joint space
and joint

Shoulder range of
motion slowly
returns to normal
(most of the
time).

1st
stage:29 mos

Shoulder stiffness (
active AND passive
range of motion in
shoulder, any
movement is mostly
scapulothoracic).
Spontaneous
resolution, selflimited disease

2nd
stage:
4-12

3rd
stage
5-24

VII.

VIII.

Clinical Signs and Symptoms/ Physical Disabilities/ Impairments

Symptoms :
- True shoulder pain
- Night pain of insidious onset
- Capsular Inflammation
- fibrous synovial adhesions
- Reduction of joint cavity
Sign:
- Painful restriction of active and passive motion
- Passive elevation less than 100
- Passive lateral rotation less than 30
- Passive medial rotation less than reaching he level of L5.
- All other shoulder conditions excluded
Diagnostic Tools/ Procedures or Test

Special test:

Speeds test
Position:
sitting with elbow at 90 flexion and slight ER, elbow extension and
forearm supination
Stimulus :
apply downward resistance into shoulder extension
(+)response:
- localized pain over biceps tedon origin
Hawkins kennedy impingement test
Position:
sitting
Stimulus:
- passive flexion to 90 and IR of the arm with the elbow flexion;
- Stabilized elbow and push down on the wrist into more IR.
(+)response:
pain in the area of supraspinatus tendon/ coracoacromial ligament
Drop arm (codmans test)
Position:
sitting/standing
Stimulus:
examiner abducts arm to 90 and pt. drops the arm slowly
(+)response:
- inability to return arm slowly or has severe pain
Neer impingement test
Position:
- Sitting
Stimulus:

Pt.s arm is forcibly elevated thru forward flexion by examiner causing

jamming of the greater tuberosity against the inferior border of the
acromion.
(+)response:
- Pain shows on pt.s face
Supraspinatus (empty can )test
Position
- Sitting
Stimulus:
- Pt.s soulder abducted to 90 with neutral rotation, examiner resist
- Shoulder is then IR(thumbs down) and angled forward 30(empty can
position) as resistance is given again.
(+)response:
- Weakness and pain
Apleys scratch test
Position
- Sitting or standing
Stimulus:
- Passive adduction, approximating elbow to opposite shoulder
(+)response:
- Pain at AC jt,.

Diagnostic tools:

IX.

Arthrogram depicts presence of adhesive capsulitis

Plain x-rays should be done to rule out concomitant pathology such as
subluxation or tumor.
Dynamic sonography may be useful to specifically identify the movements
most affected and rule out other pathology.
Laboratory tests should be considered to rule out systemic diseases.

Differential Diagnosis Conditions

Rotator Cuff
Lessions

History

Age 30-50
years
Pain and
weakness
after eccentric
load

Frozen Shoulder
-

Age 45+
Insidious
onset or after trauma
or
surgery
Functional
restriction of
lateral
rotation,
abduction,
and
medial
rotation

Atraumatic
Instability
Age
10-35 years
Pain
and instability
with activity
No history of
trauma

Cervical
Spondylosis
Age
years
Acute
chronic

50+
or

Observation

Active
movement

Passive
movement

Resisted
isometric
movement

Normal bone
and soft
tissue outlines
Protective
shoulder hike
may be seen

Weakness of
abduction or
rotation, or
both
Crepitus may
be present
Pain f
impingement
occurs

Pain and
weakness on
abduction and
lateral rotation

Normal bone
and soft
tissue
outlines

Normal bone
and soft
tissue
outlines

Restricted
ROM
Shoulder
hiking`

Full or
excessive
ROM

Limited ROM
with pain

Limited ROM,
especially in
lateral,
rotation,
abduction,
and medial
rotation
(capsular
pattern)
Normal, when
arm by side

Normal or
excessive
ROM

Limited ROM

Normal

Normal
except
if
nerve
root
compressed
Myotome
may
be
affected
Spurlins test
positive
Distraction
test positive
ULTT
positive
Shoulder
abduction
test positive
Dermatomes
affected
Reflexes
affected

Special test

Drop-arm test
positive
Empty can
positive

None

Sensory
function
reflexes
Palpation

Not affected

Not affected

Load and
shift test
positive
Apprehensio
n test positive
Relocation
test positive
Augmentatio
n test positive

and
-

Tender over
rotator cuff

Minimal or no
cervical
spine
movement
Torticollis
may
be
present

Not painful
unless
capsule is
stretched

Anterior or
posterior pain

Tender over
appropriate
vertebra or
facet

Diagnostic
imaging

X.

Radiography:
upward
displacement
of humeral
head;
acromial
spurring
MRI
diagnostic

Radiography:
negative
Anthrography
: decreased
capsular size

Negative

Radiography:
narrowing
osteophytes

Managements

Pharmacological Management
Non-steroidal anti- inflammatory drugs:
- Aspirin and ibuprofen to reduce pain and swelling
Steroid injections:
- Cortisone is a powerful anti-inflammatory medicine that injected directly
into the shoulder joint.
Medical and Surgical Management
Manipulation under anesthesia
- which may be done in combination with steroid injection, distension
arthrography, or arthroscopy.
Contraindications to closed manipulation under anesthesia include anticoagulation or bleeding diatheses, significant osteopenia, or recent
surgical repair of shoulder soft tissue, fracture or neurological lesion.
Complications may include humeral fracture, dislocation, cuff injuries,
labral tears or brachial plexus injury.
Arthroscopic capsular release or open surgical release
- may be appropriate in rare cases with failure of previous methods and
when the patient has demonstrated ability to follow through with required
physical and occupational therapy. Other disorders, such as impingement
syndrome, may also be treated at the same time. Radiofrequency is not
recommended due to reported complications from chondrolyis.
Physiotherapeutic management

Heat modalities
Heat
-

prior to exercise for pain relief, to promote relaxation and to increase tissue
extensibility

Ice/cold packs following exercises

Ultrasound

to reduce pain and inflammation

is the application of heat through sound waves to deep tissue of the body. It is
used to reduce pain, relax tight muscles and reduce muscle spasm.
Ultrasound is shown to have an analgesic effect from the vasodilatation that it
causes, which may help remove the byproducts of the injured tissue, that often
stimulates the pain fibers.
Ultrasound is also shown to relieve muscle spasms by decreasing receptor
activity and sensitivity to stretching

Transcutaneous electric stimulation (TENS):

-

TENS has been shown to significantly increase range of motion more than heat.
There are two theories of why TENS is effective in pain relief:
- The first theory the gate control theory of pain states that if the fibers
transmitting touch and proprioception sensations are over stimulated,
they may flood the pathways to the brain, preventing the pain signals
from reaching the brain.
- The second theory postulates that the electrical stimulation of nerve
fibers causes the release of bodys own natural opiates, thereby
decreasing pain.
The pain relief is directly proportional to the TENS parameters of frequency and
amplitude. As both frequency and amplitude increase, pain relief also increases

Soft tissue mobilization (STM):

-

Soft tissue mobilization and deep friction massage may have benefits in the
treatment of SAC.
Deep friction massage using the Cyriax Method is shown to be superior to
superficial heat and diathermy treatment of SAC.
Utilizing the Cyriax method, STM directed at the specific limitation of the
periarticular structures in combination with a simple home exercise program
appeared to be an effective treatment in patients with SAC stage II, as measured
by improved ROM of the subjects

Therapeutic exercises:
-

Most commonly used exercises for patients with SAC are active-assistive range
of motion (AAROM) exercises and passive ROM.
Pt uses the uninvolved arm, or equipment such as the rope and pulley, wand/ T
bar or exercise balls. Generally, these exercises are performed for flexion,
abduction and external and internal rotation range of motions. Improved in pain,
ROM, and shoulder function.

Resistive exercises
-

typically include strengthening of the scapular stabilizers, rotator cuff, and lower
trapezium muscles.
As the range of motion improves, shoulder strengthening is appropriate
intervention as long as the therapist stimulates normal movement pattern without
substitution of scapular movements over GHJ mobility.

Proprioceptive neuromuscular facilitation (PNF):

-

PNF is the application of specific stimuli to elicit and improve motor activity

Hold-relax and contract-relax techniques

-

are used frequently in the management of SAC.

During this technique, the patient will relax the antagonist muscles, and then the
physical therapist will move the limb through the available range to the point that
soft tissue limitation is felt to gain further ROM.

End range isometric exercises

-

are used for anterior deltoid muscles in the end range of forward flexion in supine
after passive stretch to train the deltoid muscles to contract isometrically for 3-5
seconds.
The patient can improve strength in the gained range during therapy sessions
and maintain this range of motion.
These techniques, when used effectively, can improve the patient outcome.

Home program
-

designed in the first treatment session by the physical therapist is individualized

and patient specific. Includes, self ROM and strengthening exercises for rotator
cuff and scapular stabilization

SPECIFIC TREATMENT TECHNIQUES BASED ON ADHESIVE CAPSULITIS STAGES

Stage 1: Painful Inflammatory Stage

Moist hot packs

AAROM with L bar
Pendulum exercise
Single-plane mobilization
Soft tissue mobilization
Postural exercise, stretching, corrections
Stretching technique (physiologic, CR,HR)
Midrange submaximal isometrics
Home program (10-12 times daily)
Motion frequently during the day
Light motion

Stage 2: Acute Adhesion with Synovitis Stage

Active warm-up
AAROM exercise
Single-plane, end-range mobilization
Stretching technique (physiologic, CR,HR)
End-range stretching
End-range submaximal isometrics
Self-capsular stretching
Home program (8-10 times daily)
Frequent stretching and ROM exercise
Sustained stretch at end range

Stage 3: Maturation Adhesion Stage

Heat
Active warm-up (AAROM,UBE)
LLLD stretch with concomitant superficial heat
Aggressive joint mobilization
Single multi-planar glides and combined glides
Joint mobilization- emphasize inferior glides
CR,HR stretching
Self- joint mobilization at home
Sustained stretching at home (TERT principle)
Strengthening (PNF)exercises
Home program (4-6 times daily)
- Keep it moving

Stage 4: Chronic Adhesion Stage

Continue all tratments listed

Durng this phase, emphasize
Oblique and mulitplanae mobilizations
Sustained LLLD stretching
Use of home LLLD device for 15-min sessions (4 times daily)
Inferior mobilizations
Postural exercises and stretching

Note: AAROM active resisted range of motion; CR contract relax; HR hold relax; LLLD low load
long duration; PNF proprioceptive neuromuscular fasciculation; TERT total end range time; UBE
upper body ergometer

XII. REFFERENCES

Physical Medicine and Rehabilitation 1st Edition by: Randall L. Braddom, M.D, M.S
Rehabilitation Medicine Principles and Practice 2nd Edition by: Joel A. DeLisa and Bruce
M. Gans
Brunnstoms clinical kinesiology 5th edition
Brunnstoms clinical kinesiology 6th edition
Handbook Of Orthopedic Surgery 10th Edition By Brashear

Pathology and Intervention in Musculoskeletal Rehabilitation By David J. Magee, James

E. Zachazewski, William S. Quillen, Robert C. Manske

Operative Arthroscopy edited by John B. McGinty, Stephen S. Burkhart

The Athlete's Shoulder By Kevin E. Wilk, Michael M. Reinold, James Rheuben Andrews