Frozen Shoulder Syndrome
Adhesive capsulitis, or “frozen shoulder syndrome” describes an ongoing and painful limitation of shoulder movement (1). Adhesive capsulitis may be classified as “primary” or “secondary” (2). Patients with “primary” adhesive capsulitis are unable to identify the cause of the condition. “Secondary” capsulitis is more common and follows a period of restricted shoulder motion (i.e. rotator cuff injury, trauma, surgery, etc) (3,4). One study found that patients who underwent a period of shoulder immobilization were 5-9 times more likely to experience adhesive capsulitis (4).
The Stages of Adhesive Capsulitis:
Adhesive capsulitis may be subdivided into 3 contiguous stages (6,7) Stage 1is recognized as the “painful” or “freezing” stage that demonstrates a gradual progressive loss of shoulder range of motion over the next weeks to months (26). The development of new nerve growth during this phase may contribute to a heightened pain response (20,26). Stage 2is the “frozen” stage, characterized by pain and significant loss of range of motion for the next several months. The shoulder undergoes progressive fibrosis, capsular thickening, and adhesions in the subarachnoid bursa, subdeltoid bursa, biceps tendon, and subscapularis tendon (8-16). This period of prolonged immobilization may lead to long-term detrimental consequences, including atrophy, degeneration, and permanent motion restrictions. Stage 3is the “thawing” stage that is associated with progressively decreasing pain and stiffness. Patients may require up to nine months to regain a functional range of motion (17-20).
Prevelance and of adhesive capsulitis:
Adhesive capsulitis is thought to affect 2-5% of the population at some point in their lifetime (21,22). Concurrent medical issues may increase one’s risk for developing adhesive capsulitis. The incidence of adhesive capsulitis rises to 10-20% in those with Type 2 diabetes, and 36% in those with Type 1 diabetes (22,23). In patients with primary adhesive capsulitis, 38% of men and 24% of women have diabetes (24). Additionally, diabetics tend to experience protracted recoveries and poorer clinical outcomes (25). Patients with thyroid disease are at increased risk for developing adhesive capsulitis (23,24). Adhesive capsulitis is most common in the 40-65-year old population with a peak incidence between 51 and 55 (26,27). Females are affected more frequently (26,28). Asians have a 3.6 times greater risk for the development of adhesive capsulitis (87). The condition shows no preference for handedness, but those who have had a prior episode in the opposite arm are at greater risk (24,26) .
Symptoms of Adhesive Capsulitis:
Patients with primary adhesive capsulitis present with gradual onset pain and stiffness that cannot be explained by their history or clinical findings.
Patients with secondary adhesive capsulitis will report shoulder pain that started following an event (i.e. fall, surgery) or another concurrent condition (i.e. rotator cuff pathology, subacromial bursitis, etc).
Symptoms of adhesive capsulitis include progressive pain, most focal to the lateral shoulder, with sharp intensification at end range motion (29). Night pain and sleep disturbances are common (29,79). Functional range of motion deficits limit reaching overhead, behind the back, or to the side (29). Patients often report difficulty grooming and dressing (26). Symptoms have generally progressed or plateaued for at least one month prior to presentation. (7)
The classic finding is a global loss of shoulder range of motion (29,31). Movement limitations greater than 25% are usually evident in at least two planes (33). The primary feature of adhesive capsulitis is painful, limited, passive external rotation. (34-38) Passive external rotation loss is often greater than 50%. (33,79) External rotation should be measured in both adduction (with the arm at the side) and abduction (with the arm in a frontal plane). (26,35) Loss of passive external rotation with the arm positioned at the side is the most common range of motion deficit in adhesive capsulitis. (35) Internal rotation deficits may be greater than external rotation deficits when the arm is positioned in 90 degrees of frontal plane abduction. (35) Passive shoulder abduction may be limited between 45 and 135 degrees- most commonly less than 100 degrees (7,79).
Normal scapular movement is responsible for up to 1/3 of total arm elevation, thus scapular dysfunction may have a significant impact on range of motion in adhesive caspulitis patients (40,41). Cervical spine intersegmental dysfunction is recognized as a contributor to other upper extremity pathologies. The cervical spine should be assessed for segmental restrictions and as a source for potential referred pain.
Are x-rays needed?
Plain film shoulder radiographs are appropriate to rule out pathology, including osteoarthritis or dislocation. (43,78) Radiographs should include an anterior-posterior (AP) view, supraspinatus outlet view, and an axillary lateral view (if possible). (43) Radiographs of patients with adhesive capsulitis are typically normal, although incidental osteoarthritic findings are common. (2) MRI is appropriate when needed to define or rule out rotator cuff pathology or when the patient does not show improvement after a reasonable period of care (6-12 weeks) (44,45).
Treatment options for adhesive capsulitis:
No single intervention seems to be significantly more effective than any other in the treatment of adhesive capsulitis (which suggests that there are no overly effective options).
A collection of studies on the effectiveness of manual therapy for the treatment of adhesive capsulitis shows varied outcomes, with the majority demonstrating improvements in range of motion, pain, and function (48-56).
Manual techniques should include active and passive stretching of the shoulder capsule with end-range mobilization (57). Several studies suggest that joint mobilization is a useful treatment strategy (58-63).
Anterior, posterior, and inferior glide mobilizations performed at the end range of abduction can produce a significant improvement in glenohumeral abduction. (63)
Scapular mobilization should be a component of treatment (40).
Cervical and thoracic spinal manipulation has been shown to be helpful in the treatment of shoulder pain and dysfunction. (80-85) Stretching exercises should be geared to correct postural deficits, including lower crossed syndrome and scapular dyskinesis. Implementation of exercises to improve scapular mobility and function are associated with improved outcomes (65).
Heat, ultrasound, and electrical stimulation modalities may provide palliative relief as an adjunct to manual therapy. (26)
Low-level laser has demonstrated effectiveness in the management of adhesive capsulitis. (86) Adhesive capsulitis has traditionally been thought of as a self-limiting disorder lasting up to 18 months, with residual motion deficits in at least 10% of patients (67,68). In some cases, symptoms may last for years (67). Patients must clearly understand the natural chronicity of this condition to limit apprehension and treatment frustration. Difficult cases may require medical and/or surgical management. Oral corticosteroids may be appropriate for severe cases with significant pain (69,70).
Intraarticular corticosteroid injections, when combined with manual therapy, may enhance short-term pain relief (26).
At Creekside Chiropractic & Performance Center, we are highly trained to treat this condition. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
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