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TECHNIQUE

Adhesive Capsulitis
Theresa A. Chiaia, PT, DPT* and Jo A. Hannafin, MD, PhDw

appropriate treatment can be administered, prognosis can be


Abstract: Adhesive capsulitis is a subset of frozen shoulder. Primary communicated, and expectations of the patient and treating
adhesive capsulitis is a distinct pathologic entity whose etiology is yet clinician can be established. Primary adhesive capsulitis will
to be determined. Understanding of this condition has evolved over the be the focus of this discussion.
centuries. Four stages of adhesive capsulitis have been established by Understanding the painful and stiff shoulder has evolved
Neviaser and Neviaser. A correlation between these findings, clinical over the centuries. Although Duplay was the first to start the
examination, and histologic appearance was later described by Han- discussion in 1872, recognizing it as a pathology, Codman, in
nafin. Diagnosis is made by physical examination and subjective his- 1934, was the first to use the term frozen shoulder and listed
tory. The stages of adhesive capsulitis represent a continuum. Clinical the diagnostic criteria as unknown etiology, global restriction
decision making can be optimized by recognizing the stage of pre- of range of movement of the shoulder, severe restriction of
sentation, as well as the irritability of the shoulder. The goals of external rotation, painful at the outset, and normal plain x-ray
treatment are to address the symptoms and impairments that the patient findings. Although he described tendinitis with secondary
presents with, and to optimize function in the presenting stage. involvement of the subacromial bursae, Codman noted that
Key Words: adhesive capsulitis, primary, frozen shoulder, physical the term frozen shoulder applies to many conditions about the
therapy shoulder. Nevaiser,13 in 1945, directed attention toward the
(Tech Should Surg 2014;15: 2–7)
capsule, describing the pathology as thickening and con-
traction of the capsule, which becomes adherent to the humeral
head, as well as the presence of reparatory inflammatory
OVERVIEW changes in the capsule. He suggested the term “adhesive
Frozen shoulder is characterized by pain with limited capsulitis” as the descriptive pathology for “frozen shoulder.”
active and passive range of motion (ROM) of the shoulder. The Lundberg,14 in 1969, documented thickening of the capsule
terms frozen shoulder and adhesive capsulitis are often used without adhesions.
interchangeably which is a misnomer. Many conditions can
cause the shoulder to become stiff and painful, or frozen, STAGES OF ADHESIVE CAPSULITIS
including pathology such as glenohumeral arthritis, acromio- Neviaser and Neviaser1 established 4 stages of the
clavicular arthritis, rotator cuff injury, calcific tendonitis, and disease—the preadhesive stage, the freezing stage, the frozen
biceps tendonitis.1 Adhesive capsulitis is a subset of frozen or maturation stage, and the thawing stage—during arthro-
shoulder. scopic evaluation in patients with arthrographically docu-
Primary adhesive capsulitis is an idiopathic condition of mented adhesive capsulitis. Hannafin et al15 described a
unknown etiology. There is a significant correlation between correlation between the arthroscopic stages described by
adhesive capsulitis and diabetes mellitus.2–4 Sixty percent of Neviaser, clinical examination, and the progressive histologic
patient with primary adhesive capsulitis have a history of appearance of capsular biopsy specimens obtained from
Dupuytren contracture.5 Thyroid dysfunction was prevalent in patients with stage 1, 2, and 3 adhesive capsulitis.
patients with adhesive capsulitis compared with an age- In stage 1, the preadhesive stage, diffuse glenohumeral
matched population.6 Fasting serum triglyceride and choles- synovitis is present on arthroscopic evaluation. Biopsy speci-
terol levels were significantly elevated in patients with mens show rare inflammatory infiltrates, a hypervascular
adhesive capsulitis compared with age-matched and sex- synovitis, and normal underlying capsule. Proliferative syno-
matched controls.7 Twenty percent to 30% recall a minor vitis with adhesion formation in the dependent fold extending
trauma to the shoulder.8 to the humeral head is observed on arthroscopy, whereas
Adhesive capsulitis occurs in 2% to 5% of the population hypervascular synovitis with perivascular scar formation and
with an age range of 35 to 70 years with the tightest dis- capsular fibroplasia with a hypercellular appearance is evident
tribution centering around 55 years.9 It is more common in on biopsy of patients in the freezing stage, that is, stage 2. The
females and in the nondominant extremity. Of significance, frozen stage, stage 3, has less synovitis with maturation and
20% to 30% of individuals with adhesive capsulitis will loss of axillary fold on arthroscopy. Specimens reveal a
develop it in the opposite shoulder; however, it rarely recurs in “burned out” synovitis with a dense, hypercellular collagenous
the same shoulder.10 tissue. In stage 4, capsular scar is mature and markedly
Primary adhesive capsulitis is a distinct pathologic entity, restrictive.
which is important to recognize and acknowledge so that
DIAGNOSIS
From the *Department of Rehabilitation, Sports Rehabilitation and Per- Diagnosis and staging of adhesive capsulitis is made by
formance Center, Hospital for Special Surgery; and wDepartment of
Orthopaedic Surgery, Weill Cornell Medical College of Cornell University,
history and physical examination. It is characterized by an
Hospital for Special Surgery, New York, NY. insidious onset of increasing pain and decreasing active and
The authors declare no conflict of interest. passive shoulder motion. In the early stages, pain is a sig-
Reprints: Theresa A. Chiaia, PT, DPT, Department of Rehabilitation, nificant feature, and the identifiers are night pain, a marked
Sports Rehabilitation and Performance Center, Hospital for Special
Surgery, 535 East 70th Street, New York, NY 10021 (e-mail:
increase in pain with sudden or unguarded movements, dis-
chiaiat@hss.edu). comfort lying on the affected side, and pain easily aggravated
Copyright r 2014 by Lippincott Williams & Wilkins by movement.16 An insidious onset of pain causes the

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Techniques in Shoulder & Elbow Surgery  Volume 15, Number 1, March 2014 Adhesive Capsulitis

individual to gradually limit use of the arm. Inflammation and CLINICAL PRESENTATION
pain causes reflex inhibition of the shoulder muscles. Disuse of The stages of adhesive capsulitis represent a continuum
the arm results in loss of shoulder mobility, whereas continued rather than distinct well-defined stages. Stage 1 is charac-
use of the arm through pain results in compensatory move- terized clinically by pain and a reluctance to move the
ments of the shoulder girdle. Subsequently, the individual shoulder. Patients report a diffuse ache that settles in the del-
gradually begins to lose motion and finds it increasingly dif- toid and sharp, sudden pain that resolves quickly with move-
ficult to perform activities of daily living that require reaching ment. Sleep is disturbed as a result of night pain, especially
overhead, out to the side, behind the back, or across the body. when lying on the affected side. There is tenderness to pal-
With time, there is a resolution of pain, but the stiffness pation of the anterior and posterior capsule. ROM assessment
persists. reveals an “empty” end feel, wherein pain stops passive
movement before resistance is felt by the clinician. Loss of
ROM is a result of pain rather than capsular contracture.
DIFFERENTIAL DIAGNOSIS
Symptoms are present for 3 months. The continuum of
Differential diagnoses are impingement syndrome, sub- symptoms progresses in stage 2. This freezing stage has
acromial bursitis, calcific tendonitis, biceps tendonitis, rotator characteristics of stage 1, acute synovitis with persistent,
cuff injury, and osteoarthritis. Patients with impingement severe pain, and stage 3, progressive capsular contracture with
demonstrate an improvement with initial treatment and do not loss of motion. ROM testing reveals a capsular end feel with
have pain with passive external rotation. Patients with bursitis pain occurring at the end of motion. Pain is reported in the
present with similar complaints of pain, but the pattern of upper trapezius and periscapular musculature as a result of
ROM loss is different with loss of elevation, internal rotation, compensatory movements. Symptoms are present for 6
and pain during end ROM. months, from months 3 to 9 since onset. Stage 3 is charac-
terized by a stiff shoulder, which is a result of decreased
DIAGNOSTIC TESTS capsular volume, and resolution of long-standing pain. There is
Imaging can be used to rule out underlying pathology. a capsular end feel and resistance is felt before pain. Pain may
Routine radiographic evaluation should include anteroposterior still be present at night. Symptoms have been present from
(AP) views in internal rotation and external rotation and month 9 to 15.
axillary and outlet views to rule out other causes of a stiff,
painful shoulder such as osteoarthritis, long-standing rotator INTERVENTION
cuff disease, and calcific tendinitis. Osteopenia may be Clinical decision making for a patient with adhesive
observed in patients with adhesive capsulitis (reference), but capsulitis can be optimized by recognizing the stage of pre-
otherwise the plain films are negative. Magnetic resonance sentation, as well as the irritability of the shoulder joint. Irri-
imaging (MRI) is not routinely recommended to diagnose tability22 is determined by pain, ROM, and extent of disability
adhesive capsulitis; however, it may be used to rule out con- and appears to correlate with the stage of adhesive capsulitis
comitant rotator cuff and/or labral pathology. If utilized, MRI (Table 1).
in stages 1 and 2 demonstrates increased signal in capsule and
synovium consistent with hyperemia and synovitis. MRI in
stages 3 and 4 demonstrates low signal capsule with capsular NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
thickening and loss of volume of the axillary pouch. Ultra- Isolated treatment with oral nonsteroidal anti-inflamma-
sonography can help differentiate rotator cuff pathology from tory drugs is yet to be proven effective.
adhesive capsulitis and identify soft tissue changes.17,18
Decrease in joint capsule volume with obliteration of the ORAL CORTICOSTEROIDS
axillary fold is observed on arthrography.19 Treatment with oral steroids appears to provide more
Intra-articular injection of steroid and local analgesic can rapid relief of pain compared with control subjects, which is
be useful in the diagnosis and treatment of adhesive capsu- similar to the effects observed following intra-articular steroid
litis.20 After injection, passive glenohumeral ROM is reeval- injection. This relief is not sustained. In addition, the potential
uated. If the patient has significant improvement in pain and for systemic side effects and the inconvenience of daily dosing
normalization of motion, the diagnosis of stage 1 adhesive does not make this an attractive option.
capsulitis is confirmed. If the patient has a significant
improvement in pain without significant improvement in
ROM, then the diagnosis is stage 2 adhesive capsulitis. CORTICOSTEROID INJECTION
Early treatment with intra-articular corticosteroid injec-
tion may provide a chemical ablation of the synovitis, thus
PHYSICAL EXAMINATION decreasing pain, improving motion, limiting the development
An upper quarter scan is performed; however, positioning of fibroplasia, and shortening the natural history of the dis-
of the upper extremity during special tests causes pain, which ease.23 Carette et al,24 in a randomized control trial (RCT),
limits their diagnostic value. ROM testing is performed and compared the efficacy of intra-articular injection, supervised
active and passive motions are measured and recorded in the physical therapy (PT), the combination of PT and injection,
upright position and in the supine position, respectively. The and placebo. Utilizing the Shoulder Pain and Disability Index,
end feel of passive movement provides useful information for the injection and PT group demonstrated faster results; how-
staging. Rundquist et al21 measured active range of motion ever, injection alone yields better results than supervised PT
(AROM) in patients with idiopathic frozen shoulder and the alone. Van der Windt et al25 compared glenohumeral intra-
most common patterns were loss of external rotation with the articular injection to PT in a prospective RCT. At 7 weeks,
arm at the side and greater loss of internal rotation than 77% of the patients treated with injection versus 46% treated
external rotation with the arm abducted as close to 90 degrees with PT were considered successes based on the patient’s self-
as possible. rating. Ryans et al26 investigated the effect of steroid injections

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Chiaia and Hannafin Techniques in Shoulder & Elbow Surgery  Volume 15, Number 1, March 2014

TABLE 1.
Stages 1 2 3 4
Duration 0-3 3-9 9-15 > 15
(mo)
Complaints Constant ache at deltoid insertion, Pain persists; severe night pain; pain Minimal pain; night pain; Shoulder
sharp pain with movement; night in upper trapezius extending to shoulder stiffness stiffness
pain neck; ROM loss
ROM A & P ROM limited by pain Loss of ROM in capsular pattern Loss of ROM in capsular Gradual ROM
pattern improvement
Signs Empty end feel; capsular pain on Pain at end ROM; hiking of shoulder Capsular end feel; resistance Capsular end
deep palpation of capsule girdle w/arm elevation before pain; hiking of the feel;
shoulder girdle w/arm resistance
elevation before pain
Diagnosis Early loss of ER ROM with intact ROM improves but is not fully No improvement in ROM with
strength; intra-articular anesthetic restored with intra-articular EUA or with local anesthetic;
injection restores ROM; EUA injection examination reveals sense of
reveals normal or minimal ROM mechanical block
loss
Diagnostic X-ray to r/o calcific tendonitis, early X-ray to r/o calcific tendonitis, early X-ray to r/o calcific tendonitis,
tests OA, long-standing RC disease; OA early OA
MRI to r/o RC injury
Arthroscopic Diffuse fibrous synovial Insertion of ‘scope reveals tight Thick capsule on insertion of Fully mature
findings inflammatory reaction; NO capsule, rubbery dense feel; Some ‘scope; loss of capsular adhesions
adhesions or capsular contracture loss of axillary fold; Christmas tree volume; remnants of fibrotic
appearance, hypervascular synovium; loss of axillary
synovitis recess
Biopsy Hypertrophic, hypervascular Hypertrophic, hypervascular Resolving synovitis; dense scar Data is not
synovitis; rare inflammatory cell synovitis; perivascular and formation in capsule available
infiltrates; normal capsule subsynovial scar; fibroplasia and
scar in the capsule
Irritability High Moderate Low
EUA indicates examination under anesthetic; MRI, magnetic resonance imaging; OA, osteoarthritis; RC, rotator cuff disease; r/o, rule out; ROM, range of motion.

(intra-articular and subacromial) and physiotherapy. At 6 management. Referral for a glenohumeral corticosteroid
weeks, the corticosteroid group/PT group demonstrated the injection is indicated to relieve pain, control inflammation,
largest change in the Shoulder Pain and Disability Index; improve motion, and ultimately halt progression through the
however, the scores were not significantly different from the stages.
corticosteroid injection only group. Oh et al,27 in a prospective The goals of treatment for the patient presenting in stage 2
RCT, divided 71 patients with primary adhesive capsulitis into are pain control, modulation of ROM loss, and reestablishment
glenohumeral or subacromial ultrasound-guided injection. The of force couples. The patient may still benefit from an injec-
GH steroid injection led to earlier pain relief. Hazelman19 tion, but ROM and joint mobilization is needed to increase
reported that the success of the treatment with injection is capsular extensibility. Recording the improvement in the ROM
dependent on the duration of symptoms; therefore, it is critical is important as the patient will continue to perceive pain at the
to determine the presenting stage. end of the ROM and may not recognize the gains. Pain-free
AROM and strengthening are performed in the plane of the
scapula (PoS) to optimize scapulohumeral rhythm and dis-
PT courage deleterious compensatory movements.
The goals of rehabilitation are to address the problems In stage 3, the patient presents with a stiff, painless
and functional impairments that the patient presents with and shoulder; thus, the goal of rehabilitation is to progress ROM
that are consistent with adhesive capsulitis. They include: pain, and flexibility and to restore function. As change in capsular
loss of function, sleep disturbance, loss of motion due to pain, extensibility takes time, the goal is to have AROM = PROM.
and/or secondary capsular tightness. Maximizing function in This allows the patient to use the arm during daily activities,
the presenting stage is the objective. This is achieved by which will enhance ROM gains and maximize function.
decreasing the inflammatory response and pain, increasing Medical massage, active warm-up, joint mobilizations, fre-
ROM, and reestablishing normal shoulder kinematics. Treat- quent ROM exercises, and active use of the arm are empha-
ment includes modalities to decrease pain and inflammation, sized. Strengthening of the periscapular musculature in the
to promote relaxation, and increase tissue extensibility; ther- available ROM will normalize scapulohumeral rhythm as
apeutic exercise and manual therapy to decrease pain, improve PROM improves.
tissue extensibility, ROM, and to reestablish force couples to Patient education is the mainstay of any rehabilitation
normalize scapulohumeral rhythm. program. In patients with adhesive capsulitis, education in the
The goal of early treatment of stage 1 is to retard the diagnosis, the stages of the disease process, and the goals for
progression from synovitis to capsular fibroplasia. Thus, each stage will encourage patient compliance and minimize
communication with the physician is paramount for successful patient frustration. The individual is taught management of

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Techniques in Shoulder & Elbow Surgery  Volume 15, Number 1, March 2014 Adhesive Capsulitis

signs and symptoms through positioning, during activities of


daily living, and a home exercise program. Helping the patient
find a position of comfort for the shoulder will afford the
patient rest. The patient is instructed to support the arm on a
pillow in supine, as the shoulder tends to be more comfortable
in the plane of the scapula with the elbow at the same height or
slightly higher than the shoulder (Fig. 1). The pillow should
also support the lack of internal rotation, thereby decreasing
the stress on the capsule and helping to relieve pain. Use of the
extremity is encouraged through movement in a pain-free arc.
Disuse of the arm will result in loss of shoulder mobility,
strength, and osteopenia, whereas continued use of the arm
through pain may result in impingement of the subacromial
space. Education regarding the importance of early recognition
and treatment and should symptoms appear in the contralateral
shoulder is discussed. It is the authors’ experience that early
treatment is associated with shorter duration of disability.
As therapeutic modalities are not used in isolation, rather
in combination with other treatment modalities, it is difficult to
assess their effectiveness. Therapeutic modalities28,29 are used
to reduce pain (transcutaneous electrical nerve stimulation and
cryotherapy), control inflammation (cryotherapy), and promote
relaxation (moist heat). Low power laser therapy was more
effective than placebo treatment in reducing pain and disability
scores.30 Ultrasound, phonophoresis, and iontophoresis
reduced the likelihood of improvement.31
Manual therapy is used throughout the course of this
disease and will be modified based on the stage and irritability
of the shoulder.22 Low-grade joint mobilization will be used in
stage 1 and early stage 2 to modulate pain.32 With decreased
capsular volume and a decrease in the axillary recess, joint FIGURE 2. P-A AROM IR in PoS in supine. AROM indicates active
mobilization will focus on tissue extensibility.33 Posterior range of motion; PoS, plane of the scapula.
directed mobilization has been shown to be more effective than
anterior directed mobilization in improving ER ROM.34 An active, pain-free warm-up utilizing upper body ergometry
Flexibility of the anterior and posterior cuff can be provides deep heating of soft tissues and increased blood flow.
addressed with stretching into ER and IR, respectively, ROM exercises37 are performed to the shoulder’s toler-
utilizing proprioceptive neuromuscular facilitation such as ance. It is important to get to know the shoulder and its
hold-relax techniques (Fig. 2). response to treatment. This will guide the dosage—frequency,
Medical massage is recommended for soft tissue release intensity, and duration—of ROM exercises. The total end
of the subscapularis35 and rotator cuff interval22,36 and to range time is determined by manipulating these variables and
achieve scapula-humeral dissociation (Figs. 3–6). is based on the irritability of the shoulder.38 ROM exercises
Therapeutic exercise will address imbalances created by beyond the shoulder’s pain threshold may delay progress.39
pain, disuse, and loss of capsular volume and contracture. Pulley exercises are introduced with adequate ROM (B135
Pendulum exercises create a distraction at the shoulder joint. degrees elevation) and humeral head control to avoid

FIGURE 1. Resting position in supine with pillow support. FIGURE 3. Subscapularis release in supine.

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Chiaia and Hannafin Techniques in Shoulder & Elbow Surgery  Volume 15, Number 1, March 2014

FIGURE 4. Progressive subscapularis release in supine. FIGURE 6. Latissimus-serratus anterior fascial release in sidelying.

anterosuperior migration and, thus, subacromial impingement. successful intervention. Early treatment, in the form of an
Advancement to self-stretching of the posterior capsule is intra-articular steroid injection, has been shown to decrease
initiated when horizontal adduction, and sleeper stretch can be pain and improve mobility in these early stages. ROM exer-
performed without impingement symptoms caused by anterior- cises in varying dosages will be prescribed in all stages. In the
superior migration of the humeral head.40 early stages, pain and inflammation will be addressed, whereas
Strengthening will focus on improving scapulohumeral in the later stages soft tissue balance will be the focus. Irre-
rhythm with emphasis on the periscapular musculature and spective of the stage of presentation, the goal of treatment was
addressing force couples41 necessary for arm elevation (ser- to optimize function in that stage.
ratus anterior, lower trapezius). Resistance exercises must be
pain-free and performed within the available arc of motion.
Closed chain exercises will help combat osteopenia and
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