Periarthritic Shoulder/Adhesive capsulitis

Periarthritic Shoulder, often referred to as Adhesive capsulitis (AC), is characterized by initially painful and later progressively restricted active and passive glenohumeral (GH) joint range of motion with spontaneous complete or nearly complete recovery over a varied period of time.This inflammatory condition causes fibrosis of the GH joint capsule, is accompanied by gradually progressive stiffness and significant restriction of range of motion (typically external rotation).

Risk Factors & Red Flags

• Diabetes mellitus (with a prevalence of up to 20%)
• Stroke
• Thyroid disorder
• Shoulder injury (direct impact, dislocation)
• Dupuytren’s disease
• Parkinson’s
• Complex regional pain syndrome
• Avascular necrosis (rare, but can occur)
• Tuberculosis
• Shortness of breath, severe cough, any compromises to the quality of the breath
• Metastatic disease
• Rheumatisms
• Multiple joint involvement
• Fever, chills, severe (inexplicable) pain
• History of cancer (to the individual, or family)
• Any suspicion of a systemic pathology or condition.

Characteristics/Clinical PresentationPatients presenting with frozen shoulder will often report an insidious onset with a progressive increase in pain, and a gradual decrease in active and passive range of motion. One of the main presenting factors is loss of external rotation (ER) in a dependent position with the arm down by the side.Patients frequently have difficulty with grooming, performing overhead activities, dressing, and particularly fastening items behind the back. Frozen shoulder is considered to be a self-limiting disease with sources stating symptom resolution as early as 6 months up to 11 years.

• Acute/freezing/painful phase: Gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and pain at night with sleep interruption which may last anywhere from 2-9 months.
• Adhesive/frozen/stiffening phase: Pain starts to subside, with progressive loss of GH motion in the capsular pattern. Pain is apparent only at extremes of movement. This phase may occur at around 4 months and last for about 12 months.
• Resolution/thawing phase: Spontaneous, progressive improvement in functional range of motion which can last anywhere from 5 to 24 months. Despite this, some studies suggest that it’s a self-limiting condition, and may last up to three years. However other studies have shown that up to 40% of patients may have persistent symptoms and restriction of movement beyond three years. It is estimated that 15% may have persistent pain and long-term disability. Effective treatments that shorten the duration of the symptoms and disability will have a significant value in reducing morbidity.

Physical Therapy Management

Initial Phase: Painful, Freezing

Pain relief and the exclusion of other potential causes of your frozen shoulder is the focus during this phase.Very gentle shoulder mobilization, muscle releases, acupuncture, dry needling, and kinesiology taping for pain relief can assist during this painful inflammation phase.  The application of a TENS machine was shown to reduce pain and increase range of motion.

Second Phase: Decreased Range of Movement

Gentle and specific shoulder joint mobilization and stretches, muscle release techniques, acupuncture, dry needling, and exercises to regain your range and strength are used for a prompt return to function. Mobilization with movement (MWM) style techniques appear the most effective and more effective than stretching exercises alone.  MWM’s are specific techniques performed by suitably trained shoulder physiotherapists.

Third Phase: Resolution

Provide you with exercise progressions including strengthening exercises to control and maintain an increased range of movement.Physiotherapy is most effective during this thawing phase. Progressed primarily by increasing stretch frequency and duration, whilst maintaining the same intensity, as tolerated by the patient.