Shoulder Pain and Mobility Deficits: Adhesive Capsulitis

Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Sectionof the American Physical Therapy Association

Recommendations


PATHOANATOMICAL FEATURES:                                                                                                      Clinicians should assess for impairments
in the capsuloligamentous complex and musculotendinous
structures surrounding the shoulder complex when
a patient presents with shoulder pain and mobility deficits
(adhesive capsulitis). The loss of passive motion in multiple
planes, particularly external rotation with the arm at the side
and in varying degrees of shoulder abduction, is a significant
finding that can be used to guide treatment planning. (Recommendation
based on theoretical/foundational evidence.)

RISK FACTORS:                                                                                                                               Clinicians should recognize that (1) patients
with diabetes mellitus and thyroid disease are at risk for
developing adhesive capsulitis, and (2) adhesive capsulitis
is more prevalent in individuals who are 40 to 65 years of
age, female, and have had a previous episode of adhesive
capsulitis in the contralateral arm. (Recommendation based
on moderate evidence.)

CLINICAL COURSE:                                                                                                                             Clinicians should recognize that adhesive
capsulitis occurs as a continuum of pathology characterized
by a staged progression of pain and mobility deficits and
that, at 12 to 18 months, mild to moderate mobility deficits
and pain may persist, though many patients report minimal
to no disability. (Recommendation based on weak evidence.)

DIAGNOSIS/CLASSIFICATION:                                                                                                      Clinicians should recognize that
patients with adhesive capsulitis present with a gradual
and progressive onset of pain and loss of active and passive
shoulder motion in both elevation and rotation. Utilizing
the evaluation and intervention components described in
these guidelines will assist clinicians in medical screening,
differential evaluation of common shoulder musculoskeletal
disorders, diagnosing tissue irritability levels, and planning
intervention strategies for patients with shoulder pain and
mobility deficits. (Recommendation based on expert opinion.)

DIFFERENTIAL DIAGNOSIS:                                                                                                        Clinicians should consider diagnostic
classifications other than adhesive capsulitis when
the patient’s reported activity limitations or impairments
of body function and structure are not consistent with the
diagnosis/classification section of these guidelines, or when
the patient’s symptoms are not resolving with interventions
aimed at normalization of the patient’s impairments of body
function. (Recommendation based on expert opinion.)

EXAMINATION – OUTCOME MEASURES:                                                                                        Clinicians should use
validated functional outcome measures, such as the Disabilities
of the Arm, Shoulder and Hand (DASH), the American
Shoulder and Elbow Surgeons shoulder scale (ASES), or
the Shoulder Pain and Disability Index (SPADI). These
should be utilized before and after interventions intended
to alleviate the impairments of body function and structure,
activity limitations, and participation restrictions associated
with adhesive capsulitis. (Recommendation based on strong
evidence.)

EXAMINATION – ACTIVITY LIMITATION MEASURES:                                                            Clinicians should utilize easily reproducible activity limitation and
participation restriction measures associated with their
patient’s shoulder pain to assess the changes in the patient’s
level of shoulder function over the episode of care. (Recommendation
based on expert opinion.)

EXAMINATION – PHYSICAL IMPAIRMENT MEASURES:                                                            Clinicians should measure pain, active shoulder range of motion
(ROM), and passive shoulder ROM to assess the key impairments
of body function and body structures in patients with
adhesive capsulitis. Glenohumeral joint accessory motion
may be assessed to determine translational glide loss. (Recommendation
based on theoretical/foundational evidence.)

INTERVENTION – CORTICOSTEROID INJECTIONS: Intra-articular
corticosteroid injections combined with shoulder mobility
and stretching exercises are more effective in providing
short-term (4-6 weeks) pain relief and improved function
compared to shoulder mobility and stretching exercises
alone. (Recommendation based on strong evidence.)

INTERVENTION – PATIENT EDUCATION:                                                                                  Clinicians should utilize patient education that (1) describes the natural course of
the disease, (2) promotes activity modification to encourage
functional, pain-free ROM, and (3) matches the intensity of
stretching to the patient’s current level of irritability. (Recommendation
based on moderate evidence.)

INTERVENTION – MODALITIES:                                                                                                 Clinicians may utilize shortwave diathermy, ultrasound, or electrical stimulation
combined with mobility and stretching exercises to reduce
pain and improve shoulder ROM in patients with adhesive
capsulitis. (Recommendation based on weak evidence.)

INTERVENTION – JOINT MOBILIZATION:                                                                                     Clinicians may utilize joint mobilization procedures primarily directed to the
glenohumeral joint to reduce pain and increase motion and
function in patients with adhesive capsulitis. (

INTERVENTION – TRANSLATIONAL MANIPULATION:                                                               Clinicians may utilize translational manipulation under anesthesia
directed to the glenohumeral joint in patients with adhesive
capsulitis who are not responding to conservative interventions.
(Recommendation based on weak evidence.)

INTERVENTION – STRETCHING EXERCISES:                                                                             Clinicians should instruct patients with adhesive capsulitis in stretching exercises.
The intensity of the exercises should be determined by
the patient’s tissue irritability level. (Recommendation based
on moderate evidence.)



INTRODUCTION

AIM OF THE GUIDELINES

The Orthopaedic Section of the American Physical Therapy
Association (APTA) has an ongoing effort to create
evidence-based practice guidelines for orthopaedic physical
therapy management of patients with musculoskeletal
impairments described in the World Health Organization’s
International Classification of Functioning, Disability and
Health (ICF).137
The purposes of these clinical guidelines are to:
• Describe evidence-based physical therapy practice, including
diagnosis, prognosis, intervention, and assessment of
outcome, for musculoskeletal disorders commonly managed
by orthopaedic physical therapists
• Classify and define common musculoskeletal conditions using
the World Health Organization’s terminology related to
impairments of body function and body structure, activity
limitations, and participation restrictions
• Identify interventions supported by current best evidence
to address impairments of body function and structure, activity
limitations, and participation restrictions associated
with common musculoskeletal conditions
• Identify appropriate outcome measures to assess changes
resulting from physical therapy interventions in body function
and structure as well as in activity and participation of
the individual
• Provide a description to policy makers, using internationally
accepted terminology, of the practice of orthopaedic
physical therapists
• Provide information for payers and claims reviewers regarding
the practice of orthopaedic physical therapy for
common musculoskeletal conditions
• Create a reference publication for orthopaedic physical
therapy clinicians, academic instructors, clinical instructors,
students, interns, residents, and fellows regarding the
best current practice of orthopaedic physical therapy




STATEMENT OF INTENT

These guidelines are not intended to be construed or to serve
as a standard of medical care. Standards of care are determined
on the basis of all clinical data available for an individual
patient and are subject to change as scientific knowledge
and technology advance and patterns of care evolve. These
parameters of practice should be considered guidelines only.
Adherence to them will not ensure a successful outcome in
every patient, nor should they be construed as including all
proper methods of care or excluding other acceptable methods
of care aimed at the same results. The ultimate judgment
regarding a particular clinical procedure or treatment plan
must be made in light of the clinical data presented by the
patient and the diagnostic and treatment options available.
However, we suggest that significant departures from accepted
guidelines should be documented in the patient’s medical
records at the time the relevant clinical decision is made.

Content experts were appointed by the Orthopaedic Section,
APTA as developers and authors of clinical practice guidelines
for musculoskeletal conditions of the shoulder that are commonly
treated by physical therapists. These content experts
were given the task of identifying impairments of body function
and structure, activity limitations, and participation restrictions,
described using ICF terminology, that could (1) categorize
patients into mutually exclusive impairment patterns upon
which to base intervention strategies, and (2) serve as measures
of changes in function over the course of an episode of care. The
second task given to the content experts was to describe interventions
and supporting evidence for specific subsets of patients
based on the previously chosen patient categories. It was
also acknowledged by the Orthopaedic Section, APTA content
experts that only performing a systematic search and review of
the evidence related to diagnostic categories based on International
Statistical Classification of Diseases and Related Health
Problems (ICD)136 terminology would not be sufficient for these
ICF-based clinical practice guidelines, as most of the evidence
associated with changes in levels of impairment or function
in homogeneous populations is not readily searchable using
the ICD terminology. Thus, the authors of these guidelines
independently performed a systematic search of MEDLINE,
CINAHL, and the Cochrane Database of Systematic Reviews
(1966 through September 2011) for any relevant articles related
to classification, examination, and intervention for musculoskeletal
conditions related to classification, outcome measures,
and intervention strategies for shoulder adhesive capsulitis
and frozen shoulder. Additionally, when relevant articles were
identified, their reference lists were hand searched in an attempt
to identify other relevant articles. These guidelines were
issued in 2013, based on publications in the scientific literature
prior to September 2011. These guidelines will be considered
for review in 2017, or sooner if new evidence becomes available.
Any updates to these guidelines in the interim period will
be noted on the Orthopaedic Section of the APTA website:

www.orthopt.org.



Methods

LEVELS OF EVIDENCE

Individual clinical research articles were graded according to
criteria described by the Centre for Evidence-Based Medicine,
Oxford, UK (http://www.cebm.net) for diagnostic, prospective,
and therapeutic studies.100 An abbreviated version of the
grading system is provided as follows.


I-Evidence obtained from high-quality diagnostic studies,
prospective studies, or randomized controlled trials
II-Evidence obtained from lesser-quality diagnostic studies,
prospective studies, or randomized controlled trials (eg,
weaker diagnostic criteria and reference standards, improper
randomization, no blinding, less than 80% follow-up)
III- Case-controlled studies or retrospective studies
IV- Case series
V- Expert opinion

GRADES OF EVIDENCE

The overall strength of the evidence supporting recommendations
made in these guidelines was graded according to guidelines
described by Guyatt et al,48 as modified by MacDermid
et al73 and adopted by the coordinator and reviewers of this
project. In this modified system, the typical A, B, C, and D
grades of evidence have been modified to include the role of
consensus expert opinion and basic science research to demonstrate
biological or biomechanical plausibility.

GRADES OF RECOMMENDATION
BASED ON STRENGTH OF EVIDENCE

A-Strong evidence- A preponderance of level I and/or
level II studies support the recommendation.
This must include at least 1 level I study

B-Moderate evidence-
A single high-quality randomized controlled
trial or a preponderance of level
II studies support the recommendation

C-Weak evidence A single level II study or a preponderance
of level III and IV studies,
including statements of consensus
by content experts, support the
recommendation

D-Conflicting evidence-
Higher-quality studies conducted on
this topic disagree with respect to their
conclusions. The recommendation is
based on these conflicting studies

E-Theoretical/foundational evidence
A preponderance of evidence from
animal or cadaver studies, from
conceptual models/principles, or from
basic science/bench research supports
this conclusion

F-Expert opinion -Best practice based on the
clinical experience of the guidelines development team


REVIEW PROCESS

The Orthopaedic Section, APTA also selected consultants
from the following areas to serve as reviewers of the early
drafts of these clinical practice guidelines:
• Claims review
• Coding
• Epidemiology
• Medical practice guidelines
• Orthopaedic physical therapy residency education
• Orthopaedic physical therapy clinical practice
• Orthopaedic surgery
• Rheumatology
• Physical therapy academic education
• Sports physical therapy/rehabilitation clinical practice
• Sports physical therapy residency education
Comments from these reviewers were utilized by the authors
to edit these clinical practice guidelines prior to submitting
them for publication to the Journal of Orthopaedic & Sports
Physical Therapy.

CLASSIFICATION

The terms adhesive capsulitis, frozen shoulder, and periarthritis
have been used for patients with shoulder pain and
mobility deficits. Adhesive capsulitis will be used in these
guidelines to describe both primary idiopathic adhesive capsulitis
and secondary adhesive capsulitis related to systemic
disease, such as diabetes mellitus and thyroid disorders, as
well as extrinsic or intrinsic factors, including cerebral vascular
accident, proximal humeral fracture, causative rotator
cuff, or labral pathology. The term adhesive capsulitis is used,
rather than frozen shoulder, because it is the term used in
the ICD.
The ICD-10 code associated with adhesive capsulitis is
M75.0. The corresponding ICD-9-CM code, commonly used
in the United States, is 726.0.
The primary ICF body function codes associated with shoulder
pain and mobility deficits/adhesive capsulitis are b28014
pain in the upper limb, b28016 pain in joints, and b7100
mobility of a single joint. The primary ICF body structure
codes associated with adhesive capsulitis are s7201 joints
of shoulder region and s7203 ligaments and fasciae of
shoulder region.
The primary ICF activities and participation codes associated
with adhesive capsulitis are d4150 maintaining a lying position,
d5400 putting on clothes, d5401 taking off clothes,
and d4452 reaching. The secondary ICF activities and
participation codes associated with adhesive capsulitis are
d2303 completing the daily routine, d4300 lifting, d4302
carrying in the arms, d4454 throwing, d4551 climbing,
d4554 swimming, d5100 washing body parts, d5101 washing
whole body, d5202 caring for hair, d6201 gathering
daily necessities, d6402 cleaning living area, d6501 maintaining
dwelling and furnishings, d6600 assisting others
with self-care, and d9201 sports.


CLINICAL GUIDELINES

Impairment/Function-Based Diagnosis

PREVALENCE

The prevalence of shoulder pain has been reported to be between
2.4% and 26%.25,69 Primary adhesive capsulitis is reported
to affect 2% to 5.3% of the general population.5,17,71,97
The prevalence of secondary adhesive capsulitis related to
diabetes mellitus and thyroid disease is reported to be between
4.3% and 38%.5,7,17,71,97 Milgrom et al77 compared 126
patients (76 women; mean  SD age, 55.0  8.4 years; 50
men; mean  SD age, 54.7  8.7 years) with idiopathic
adhesive capsulitis to prevalence data and found a significantly
higher prevalence of diabetes among both women
(23.7% versus 4.7%) and men (38.0% versus 6.5%) with
adhesive capsulitis as compared to the age-matched population.
The type of diabetes, type 1 or 2, was not identified.
A significantly higher prevalence of hypothyroidism among
women (21.1% versus 7.9%) with idiopathic adhesive capsulitis

was found compared to the age-matched regional population.77


PATHOANATOMICAL FEATURES

The glenohumeral joint is a synovial joint containing a synovial
membrane lining the interior joint capsule and encasing
the long head of the biceps tendon into the biceps groove. The
glenohumeral capsule, coracohumeral ligament, and glenohumeral
ligaments (superior, middle, and inferior) comprise
the capsuloligamentous complex. This complex surrounds
the glenohumeral joint inserting onto the humerus (superior
to the lesser tuberosity and surgical and anatomic necks),
from the coracoid and glenoid rim via the labrum and glenoid
neck. The capsuloligamentous complex and rotator cuff
tendons create an intimate static and dynamic constraining
sleeve around the glenohumeral joint.28,99


II-Cadaver studies demonstrate the restricting Cadaver studies demonstrate the restricting influence
of the subscapularis and selected capsuloligamentous
complex portions.95,125 The proximal
portion of the capsuloligamentous complex and the subscapularis
were found to limit external rotation when the
glenohumeral joint was positioned up to 45° of abduction.
Turkel et al125 found that the subscapularis limited external
rotation the most with the arm at 0° of abduction. It has been
suggested that a greater loss of external rotation at 45° versus
90° of abduction indicates subscapularis restriction.44

II-The rotator cuff interval forms a triangular-shaped
tissue bridge between the anterior supraspinatus
tendon edge and the upper subscapularis border,
with the apex located on the biceps sulcus lateral ridge at
the margin of the transverse humeral ligament.102 The rotator
cuff interval is primarily composed of the superior glenohumeral
ligament and the coracohumeral ligament.29,36,63,103
Recently, the anterosuperior capsule was found to have not
only an anterior limb but also a posterior limb containing
the previously unrecognized posterosuperior glenohumeral
unrecognized posterosuperior glenohumeral
ligament.103

IV-Adhesive capsulitis is marked by the presence of
multiregional synovitis, consistent with inflammation,
50,83,84,88,133 yet focal vascularity and synovial angiogenesis
(increased capillary growth) rather than synovitis
are described by others.20,55,134,135 Accompanying angiogenesis,
there is evidence of new nerve growth in the capsuloligamentous
complex of patients with adhesive capsulitis, which may
explain the heightened pain response.49 Regardless of the synovial
pathology being angiogenesis or synovitis, significant
pain can result at rest or with motion.

IV-Significant capsuloligamentous complex Significant capsuloligamentous complex fibrosis
and contracture are consistently observed upon
open or arthroscopic shoulder surgery and histologic
examination. The entire capsuloligamentous complex
can become fibrotic, but the rotator cuff interval and specifically
the capsuloligamentous complex are predominantly
involved.55,82,83,92,94,96,126,127,134 The rotator cuff interval is part
of the anterosuperior complex, which functions as a superior
hammock. With the arm at the side, the anterior limb
restricts external rotation while the posterior limb restricts
internal rotation.51,103 Coracohumeral ligament release in
patients with adhesive capsulitis resulted in a dramatic increase
in shoulder external rotation motion.50,82,92,94,96 Others
have noted significant subacromial scarring,55,85 loss of the
subscapular recess,71,86 inflammation of the long head of the
biceps tendon and its synovial sheath,133 and musculotendinous contracture.85


E-Clinicians should assess for impairments in the
capsuloligamentous complex and musculotendinous
structures surrounding the shoulder complex
when a patient presents with shoulder pain and mobility
deficits (adhesive capsulitis). The loss of passive motion in
multiple planes, particularly external rotation with the arm
at the side and in varying degrees of shoulder abduction,
is a significant finding that can be used to guide treatment
planning


RISK FACTORS

III-Although the etiology of adhesive capsulitis has not
been identified, there are a number of associated
factors. Recent evidence implicates elevated serum
cytokine levels as causing or resulting in a sustained intense
and protracted inflammatory/fibrotic response affecting the
synovial lining and capsuloligamentous complex in patients
with adhesive capsulitis.21,54,113 To date, the relationship between
cytokines and the causative factor, whether it is insidious
or related to minor trauma, is unknown.

III-Individuals with type 1 or 2 diabetes mellitus have
a greater propensity of developing adhesive capsulitis.
7,20,77,78,97 Patients with Dupuytren’s disease or
type 1 diabetes mellitus for 10 or more years have a greater
incidence of primary adhesive capsulitis.5,7,20


II-Milgrom et al,77 in a prospective study, identified
risk factors associated with idiopathic adhesive
capsulitis by comparing the prevalence of diabetes
in new cases (n = 126) to age-matched controls over a 2.5-
year period. Of the 126 new cases, 29.3% had diabetes mellitus.
Patients with adhesive capsulitis had a higher rate of
diabetes mellitus compared to an age-matched population,
as indicated by the risk ratios of 5.9 (95% confidence interval
[CI]: 4.1, 8.4) in men and 5.0 (95% CI: 3.3, 7.5) in women.
Balci et al7 evaluated patients with type 2 diabetes mellitus
(n = 297; 60% female) to determine the presence of adhesive
capsulitis and other conditions. They found that 29% (men,
33.6%; women, 25.9%) had adhesive capsulitis, as defined by
having at least 1 month of shoulder pain, an inability to lie on
the affected side, and restricted active and passive shoulder
motion in 3 or more planes. Additionally, they found a significant
relationship between adhesive capsulitis and Dupuytren’s
contracture. Adhesive capsulitis was associated with
age (mean  SD, 59.23  8.24 years) and the duration of
diabetes. Aydeniz et al5 compared 102 patients (mean  SD
age, 58.0  9.1 years) with type 2 diabetes mellitus to an ageand
sex-matched control group and found that 14.7% had
adhesive capsulitis, compared to 3.9% of the controls. The incidence
of Dupuytren’s contracture was higher in the diabetic gr
8oup (12.7%) versus the control group (3.9%). There were
significant associations between age, diabetes duration, and
musculoskeletal complications (ie, Dupuytren’s contracture
trigger finger).

II-Age can be considered a risk factor because adhesive
capsulitis more commonly occurs in individuals
between 40 and 65 years of age, with the
reported peak incidence occurring, on average, between 51
and 55.71,84,87,89,97 Females appear to be affected more commonly
than males.5,12,50,71,77,120 However, a greater proportion
of males (33.6%) than females (25.9%) had adhesive capsulitis
in an identified group of patients with diabetes mellitus.7
Having adhesive capsulitis on 1 side places an individual at
risk (5%-34%) for opposite-arm involvement in the future,
and adhesive capsulitis can occur bilaterally simultaneously
up to 14% of the time.18,45,71,119

IV-Other associated risk factors include prolonged immobilization,
myocardial infarction, trauma, and
autoimmune disease.16,18,104,111,140


B-Clinicians should recognize that (1) patients with
diabetes mellitus and thyroid disease are at risk for
developing adhesive capsulitis, and (2) adhesive
capsulitis is more prevalent in individuals who are 40 to 65
years of age, female, and have had a previous episode of adhesive
capsulitis in the contralateral arm.


CLINICAL COURSE

Four stages of adhesive capsulitis, reflecting a continuum,
have been described.50,83,89 Stage 1 may last up to 3 months,
and during this stage patients describe sharp pain at end
ranges of motion, achy pain at rest, and sleep disturbance.
During this stage, arthroscopic examination reveals diffuse
synovial reaction without adhesions or contracture.50,83,89
Subacromial shoulder impingement is often the suspected
clinical diagnosis early in this stage because there are minimal
to no ROM restrictions.83,89 Early loss of external rotation motion with an intact rotator cuff is a hallmark sign of adhesive capsulitis and may be seen in this stage.37,83 Stage
2, known as the “painful” or “freezing” stage, presents with a
gradual loss of motion in all directions due to pain and can
last from 3 to 9 months. Arthroscopic examination reveals
aggressive synovitis/angiogenesis and some loss of motion
under anesthesia.50,83,89 Stage 3, known as the “frozen” stage,
is characterized by pain and loss of motion and lasts from 9
to 15 months. In stage 3, the synovitis/angiogenesis lessens
but the progressive capsuloligamentous fibrosis results in loss
of the axillary fold and ROM when tested under anesthesia.
50,83,89 Stage 4, known as the “thawing” stage, is characterized
by pain that begins to resolve, but significant stiffness
persists from 15 to 24 months after onsets of symptoms.50,89,90
This stage often progresses to pain resolution, but motion
restrictions may persist that are unchanged even when examined
under anesthesia. Arthroscopy reveals capsuloligamentous
complex fibrosis and receding synovial involvement.83,89
Although adhesive capsulitis was initially considered a 12- to
18-month self-limited process, mild symptoms may persist
for years, depending on the extent of fibroplasia and subsequent
resorption.11,19,30,31,45,119 Patients with diabetes mellitus
may have a protracted recovery and worse outcomes.


II-Binder et al11 performed a prospective study (n =
40) on patients with adhesive capsulitis. Patients
were classified as having adhesive capsulitis if they
had shoulder pain for at least 1 month, sleep disturbance due
to pain, an inability to lie on the affected shoulder, restriction
in all active and passive shoulder movements, and at least a
50% reduction in external rotation motion. The investigators
did not state whether the 50% loss of external rotation
was compared to established norms or compared to the uninvolved
extremity. The authors noted that at 6 months and at a
minimum of 3 years after the diagnosis, 90% and 40% of the
patients, respectively, had not regained normal ROM when
compared to an age- and sex-matched control group. They
concluded that at a long-term follow-up (mean, 44 months),
measurable mobility deficits persisted but patients had little
functional deficits.




IV-Griggs et al45 assessed 75 patients who fit the criteria
for stage 2 adhesive capsulitis. In addition, the
patients had a history of no or only trivial shoulder
trauma; loss of active and passive shoulder ROM (more than
a 50% loss of external rotation), especially with the shoulder
abducted at 90°; pain at the extremes of all shoulder motions;
globally limited glenohumeral joint translation; and
normal glenohumeral joint radiographic findings. The investigators
found that 27% of these 75 patients continued
to have mild pain with activity and that all patients demonstrated
mobility deficits compared to their uninvolved side
at an average of 22 months following the onset of adhesive
capsulitis. The vast majority of patients (90%) were satisfied
with their outcome. Less than half (40%) reported residual
shoulder disability, with an average  SD score of 9.7  13.6
points on the DASH questionnaire (range of score from 0 to
100, with 0 representing no disability). However, ROM did
not correlate with patient-rated outcome scores on the simple
shoulder test (SST) and the DASH, but pain with activity rating
did correlate with functional loss. Diabetes mellitus and
male gender were related to worse ROM outcomes. Seven
percent of the patients were eventually treated with manipulation
under anesthesia and/or capsular release. A history of
prior rehabilitation and workers’ compensation or pending
litigation was associated with being treated with manipulation
and/or capsular release.

IV-Shaffer et al119 retrospectively examined patients
with adhesive capsulitis (n = 62) who were treated
conservatively. The criteria for inclusion were a
minimum of 1 month of shoulder pain and stiffness for which
no other cause could be identified, documented restriction
of passive glenohumeral and scapulothoracic motion of 100°
of abduction or less, and less than 50% of external rotation
when compared to the contralateral shoulder. In an average
of 6 months, pain resolved and motion returned to normal or
within 10° to 15° of normal. At an average of a 7-year followup,
89% of patients had no functional deficits, but 50% continued
to report mild pain or stiffness. However, ROM loss
did not correlate with functional deficits.



IV-Levine et al68 performed a retrospective review of 98
patients (105 shoulders) with the diagnosis of idiopathic
adhesive capsulitis. The criteria for inclusion
were diagnosis of adhesive capsulitis and treatment by 1 of
4 shoulder surgeons. The Medical Outcomes Study 36-Item
Short-Form Health Survey (SF-36), the ASES, and the SST
were used as patient-rated outcome measures, and ROM as the
impairment measure. The average duration of treatment was
4.7 months, and 18.1% of the patients had diabetes mellitus.
Symptoms resolved in 89.5% of the patients who were managed
with physical therapy, nonsteroidal anti-inflammatory
drugs, intra-articular corticosteroid injections, or some combination
of the 3. No difference in recovery was seen between
patients with diabetes mellitus and those without diabetes.
Ten percent of the patients required operative management,
with this group demonstrating greater loss of elevation and external
rotation ROM both initially and preoperatively. Therefore,
those who required surgery had less shoulder ROM at
the time of diagnosis, and their ROM continued to decrease
during the course of nonoperative treatment.


C-Clinicians should recognize that adhesive capsulitis occurs as a continuum of pathology characterizedby a staged progression of pain and mobility deficits and that, at 12 to 18 months, mild to moderate mobilitydeficits and pain may persist, though many patients report minimal to no disability




DIAGNOSIS/CLASSIFICATION

DIAGNOSIS

V-The diagnosis of shoulder pain and mobility deficits
associated with primary or secondary adhesive capsulitis
is determined from the history and physical
examination. Patients typically present with a gradual and
progressive onset of pain, likely sleep-disturbing night pain
and pain at end ranges of movements. Patients also present
with painful and restricted active and passive ROM in both
elevation and rotation that occurs for at least 1 month and
has either reached a plateau or worsened.11 Functional activities
such as reaching overhead, behind the back, or out
to the side become increasingly difficult due to pain and/or
stiffness.


III-The primary purpose for diagnosis/classification
of shoulder pain is to direct intervention
and inform prognosis. Traditionally, a pathoanatomic
model has been used to identify the symptomatic
tissue(s) and distinguish among various pathologies.
A proposed classification scheme140 suggests that primary
frozen shoulder and idiopathic adhesive capsulitis are considered
identical and not associated with a systemic condition
or history of injury. Furthermore, secondary adhesive
capsulitis or frozen shoulder is defined by a relationship
between a disease or pathology with 3 subcategories: systemic,
extrinsic, and intrinsic. Systemic secondary adhesive
capsulitis includes those patients with a history of diabetes
mellitus and thyroid disease. Extrinsic secondary adhesive
capsulitis includes patients whose pathology is not directly
related to the shoulder, yet it results in a painful and stiff
shoulder, such as with a cerebral vascular accident, intrathoracic
conditions (eg, myocardial infarction and chronic
obstructive pulmonary disease), intra-abdominal conditions
(eg, chronic liver disease), cervical disc disease, distal
extremity fracture, or self-imposed immobilization. Intrinsic
secondary adhesive capsulitis describes patients with a
known pathology of the glenohumeral joint soft tissues or
structures, such as rotator cuff tendinopathy, biceps tendinopathy,
calcific tendinitis, acromioclavicular or glenohumeral
joint arthropathy, or proximal humeral or scapular
fracture.140 Loss of shoulder ROM and pain that is associated
with postoperative stiffness should not be considered
adhesive capsulitis. These categorizations present a theoretical
framework; however, there is a lack of evidence with
regard to their ability to drive treatment decision making
and to prognosticate outcome.

CLASSIFICACION

V-Patients with adhesive capsulitis present with a
number of impairments, but most characteristically
have a global loss of both active and passive
shoulder ROM.50 Generally, ROM loss of greater than 25%
in at least 2 planes and passive external rotation loss that
is greater than 50% of the uninvolved shoulder or less than
30° of external rotation have been used to define adhesive
capsulitis.12,19,20,23,37,45,61,82,85,106,110,119,131,132 The capsular pattern
described by Cyriax,37 where external rotation motion
loss is proportionally greater than loss of abduction, which
is more limited than internal rotation, is not consistently
found when objective measurements are taken. Rundquist
et al116 found varying patterns of restriction in patients with
adhesive capsulitis, but the most common pattern was a
loss of external rotation with the arm at the side followed
by a loss of abduction and internal rotation. A consistent
finding was a greater loss of internal rotation versus external
rotation when the arm was positioned as close as
possible to 90° of frontal plane abduction.116 Cyriax37 described
patients with adhesive capsulitis as having normal
strength and painless responses to resisted tests. However,
others have described patients with adhesive capsulitis as
having reduced shoulder muscle strength with isometric
testing,58,66,121 specifically weakness of the internal rotators,
58,66 elevators,66,121 and external rotators. Special tests,
such as impingement signs and the Jobe test, are not helpful
in differentiating adhesive capsulitis from rotator cuff
tendinopathy, as they reproduce pain because they involve
end-range positioning of the painful and stiff capsuloligamentous
complex.




V-A medical diagnosis of adhesive capsulitis may
be helpful in describing the tissue pathology, but
it does not aid in treatment decision making for
rehabilitation. An impairment-based classification is necessary
to guide rehabilitation; however, there is no published
classification system. Thus, the current guidelines include a
proposed model for diagnosis, examination, and treatment
planning for patients with shoulder pain and mobility deficits,
using the following components:
• Evaluation/Intervention Component 1: medical screening
• Evaluation/Intervention Component 2: differential evaluation
of clinical findings suggestive of musculoskeletal
impairments of body functioning (ICF) and the associated
tissue pathology/disease (ICD)
• Evaluation/Intervention Component 3: diagnosis of tissue
irritability level
• Evaluation/Intervention Component 4: intervention strategies
for shoulder pain and mobility deficits




Component 1

Medical screening incorporates the findings of the history
and physical examination to determine whether the patient’s
symptoms originate from a more serious pathology, such as
a tumor or infection, rather than from a common shoulder
musculoskeletal disorder.80,139 In addition to serious medi-
cal conditions, clinicians should screen for the presence of
psychosocial issues that may affect prognostication and
treatment decision making for rehabilitation. For example,
elevated scores on the Tampa Scale of Kinesiophobia or the
Fear-Avoidance Beliefs Questionnaire have been associated
with a longer recovery, chronic symptoms, and work loss in
patients with shoulder pain.42,59,79 Accordingly, identifying
cognitive behavioral tendencies during the patient’s evaluation
can direct the therapist to employ specific patient education
strategies to optimize patient outcomes to physical
therapy interventions and potentially provide indications for
referring the patient for consultation with another medical or
mental health practitioner.10


Component 2

Differential evaluation of musculoskeletal clinical findings is
used to determine the most relevant physical impairments associated
with the patient’s reported activity limitations and
medical diagnosis. Clusters of these clinical findings, which
commonly coexist in patients, are described as impairment
patterns in the physical therapy literature1 and are labeled
according to the key impairment(s) of body function associated
with that cluster. These impairment patterns are useful
in driving the interventions, which focus on normalizing the
key impairments of body function, which in turn improves the
movement and function of the patient and lessens or alleviates
the activity limitations commonly reported by the patients
who meet the diagnostic criteria of that specific pattern. Key
clinical findings to rule in and rule out the common impairment
patterns, and their associated medical conditions, are
shown in the FIGURE. Impairment-based classification is critical
for matching the intervention strategy that is most likely to
provide the optimal outcome for a patient’s clinical findings.
However, it is important for clinicians to understand that patients
with shoulder pain often fit more than 1 impairment
pattern and that the most relevant impairments of body function
and the associated intervention strategies often change
during the patient’s episode of care. Thus, continual re-evaluation
of the patient’s response to treatment and the patient’s
emerging clinical findings is important for providing the optimal
interventions throughout the patient’s episode of care.

Component 3

Diagnosis of tissue irritability is important for guiding the
clinical decisions regarding treatment frequency, intensity,
duration, and type, with the goal of matching the optimal
dosage of treatment to the status of the tissue being treated.
Irritability is a term used by rehabilitation practitioners to
reflect the tissue’s ability to handle physical stress,81 and is
presumably related to physical status and the extent of inflammatory
activity that is present. Three levels of irritability
are operationally defined in the FIGURE. The primary clinical
finding that determines the level of tissue irritability is the
relation between pain and active and passive movements.
Other clinical findings that characterize the level of tissue
irritability are pain level, frequency of pain, and level of disability
reported by the patient.



Component 4

Because irritability level often reflects the tissue’s ability to
accept physical stress, clinicians should match the most appropriate
intervention strategies to the level of irritability.60
Patients with a high level of tissue irritability are not ready for
significant physical stress being applied to the affected tissues,
and therefore the treatment should emphasize activity modification
and appropriate modalities, medication, and manual
therapy to relieve pain and inflammation. In addition, only low
levels of glenohumeral exercises should be performed while
encouraging motion at adjacent regions. Patients with a moderate
level of irritability should be able to tolerate controlled
physical stress in the form of progressive manual therapy, mild
stretching, and strengthening activities. They should also be
able to perform basic functional activities. In comparison, patients
with low irritability should be able to tolerate progressive
physical stress in the form of stretching, manual therapy,
resistive exercise, and higher-demand physical activities.

F-Clinicians should recognize that patients with adhesive
capsulitis present with a gradual and progressive
onset of pain and loss of active and passive
shoulder motion in both elevation and rotation. Utilizing
the evaluation and intervention components described in
these guidelines will assist clinicians in medical screening,
differential evaluation of common shoulder musculoskeletal
disorders, diagnosing tissue irritability levels, and planning
intervention strategies for patients with shoulder pain and
mobility deficits.

DIFFERENTIAL DIAGNOSIS

In addition to the 3 most common shoulder conditions outlined
in the Diagnosis/Classification section of these clinical
guidelines—adhesive capsulitis; sprain and strain of shoulder
joint/dislocation; and rotator cuff syndrome/tendinopathy of
the supraspinatus, infraspinatus, and biceps brachii—the following
conditions, using ICD-10 terminology,136 should be
considered in the differential diagnosis when a patient presents
with shoulder pain:
• Acute calcific tendonitis/bursitis
• Arthrosis of the shoulder, primary
• Arthrosis of the shoulder, secondary
• Bursitis of the shoulder
• Cervicalgia
• Cervical disc disorders
• Cervicobrachial syndrome
• Contusion of shoulder and upper arm
• Diseases of the digestive system
• Fibromyalgia
• Fracture of clavicle
• Fracture of scapula
• Fracture of shaft of humerus
• Fracture of upper end of humerus
• Impingement syndrome of the shoulder
• Injury of blood vessels at shoulder and upper-arm level,
including avascular necrosis
• Injury of muscle and tendon at shoulder and upper-arm
level, including labral lesions
• Injury of nerves at shoulder and upper-arm level, including
suprascapular nerve entrapment
• Juvenile rheumatoid arthritis
• Neoplasm
• Osteoarthritis of the acromioclavicular joint
• Osteoarthritis of the cervical spine
• Osteoarthritis of the glenohumeral joint
• Osteoporosis with pathological fracture
• Pain in thoracic spine
• Persistent somatoform pain disorder
• Psychological and behavioral factors associated with disorders
or diseases
• Pyogenic arthritis
• Radiculopathy
• Rheumatoid arthritis
• Somatoform autonomic dysfunction
• Sprain and strain of acromioclavicular joint