International Journal of Physical Education, Sports and Health 2019; 6(2): 12-16

P-ISSN: 2394-1685
E-ISSN: 2394-1693
Impact Factor (ISRA): 5.38
Physiotherapy of adhesive capsulitis: A review
IJPESH 2019; 6(2): 12-16
© 2019 IJPESH
www.kheljournal.com Kaushik Guha
Received: 13-01-2019
Accepted: 15-02-2019
Abstract
Kaushik Guha
Adhesive capsulitis and frozen shoulder syndrome (FSS) are two terms that have been used to describe a
Peerless College of painful and stiff shoulder. The current consensus definition of a frozen shoulder by the American
Physiotherapy, Peerless Hospital Shoulder and Elbow Surgeons is "a condition of uncertain etiology characterized by significant
& B. K. Roy Research Centre, restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic
Affiliated To the West Bengal shoulder disorder." The American Academy of Orthopaedic Surgeons defines this condition as: "A
University of Health Sciences, condition of varying severity characterized by the gradual development of global limitation of active and
Kolkata, West Bengal, India passive shoulder motion where radiographic findings other than osteopenia are absent. The loss of
passive range of motion (ROM) is a critical element in establishing the diagnosis of a true frozen
shoulder. Although conditions such as sub acromial bursitis, calcifying tendinitis, and partial rotator cuff
tears can be associated with significant pain and loss of active ROM, passive ROM is preserved. There is
no consensus on how the best way best to manage patients with this condition, so I want to provide an
evidence-based overview regarding the effectiveness of shoulder mobilization, electrotherapy and
exercise therapy in physiotherapy to treat adhesive capsulitis.

Keywords: Physiotherapy, adhesive capsulitis, frozen shoulder

1. Introduction
Adhesive capsulitis and frozen shoulder syndrome (FSS) are two terms that have been used to
describe a painful and stiff shoulder. The current consensus definition of a frozen shoulder by
the American Shoulder and Elbow Surgeons is "a condition of uncertain etiology characterized
by significant restriction of both active and passive shoulder motion that occurs in the absence
of a known intrinsic shoulder disorder [1]."
The American Academy of Orthopaedic Surgeons defines this condition as: "A condition of
varying severity characterized by the gradual development of global limitation of active and
passive shoulder motion where radiographic findings other than osteopenia are absent."
The loss of passive range of motion (ROM) is a critical element in establishing the diagnosis
of a true frozen shoulder. Although conditions such as subacromial bursitis, calcifying
tendinitis, and partial rotator cuff tears can be associated with significant pain and loss of
active ROM, passive ROM is preserved [2].
There is no consensus on how the best way best to manage patients with this condition, so I
want to provide an evidence-based overview regarding the effectiveness of shoulder
mobilization, electrotherapy and exercise therapy in physiotherapy to treat adhesive capsulitis.

2. Materials and methods

Adhesive capsulitis is characterized by a marked loss active and passive shoulder motion
caused by inflammation and adherence of the capsule to the anatomic neck of the humerus and
to itself at the inferior axillary fold. Joint volume is decreased to less than 10 to 12 ml (normal
is 20 ml). The criteria for diagnosis of a “frozen shoulder” are not universally accepted, but the
following general criteria are applicable:
Correspondence
Kaushik Guha 1. Decreased glenohumeral motion and loss of synchronous shoulder girdle motion,
Peerless College of 2. Restricted elevation (less than 135 or 90 degrees depending on the author),
Physiotherapy, Peerless Hospital 3. External rotation 50% to 60% of normal,
& B. K. Roy Research Centre, 4. Arthrogram findings 5 to 10 cc volume with obliteration of normal axillary fold [3].
Affiliated To the West Bengal Primary adhesive capsulitis (AC) is a shoulder condition characterized by a gradual and
University of Health Sciences,
Kolkata, West Bengal, India painful loss of both active and passive range-of-motion (ROM) in all planes of glenohumeral
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joint, especially external rotation, resulting from progressive degree of pain and stiffness. Initial therapy typically includes
fibrosis and contracture of the glenohumeral joint capsule [4]. gentle range-of-motion exercises, although evidence is
Duplay [5] in 1872 was the first author who described this lacking. Other therapies, such as ultrasound, massage,
condition as “periarthritis”. In 1934 Codman [6] used the term iontophoresis, and phonophoresis, have not been proven
“Frozen shoulder” to define a gradually developing condition, effective for adhesive capsulitis [15].
characterized by pain near the deltoid insertion, inability to D. Y. Bulgen et al. In a RCT “Frozen shoulder: prospective
sleep on the affected side, painful and restricted elevation and clinical study with an evaluation of three treatment regimens”
external rotation and a normal radiological appearance. In randomly divided 42 patients in to four groups. First group
1945 Neviaser defined this condition “Adhesive capsulitis” in (11 patients) received Methyl prednisolone acetate 20 mg and
order to underline the inflammatory pathogenesis and fibrosis 1% lignocaine hydrochloride 0-5 ml, second group (11
[4]
. Later histologic studies confirmed the presence of patients) received Maitland’s mobilization, third group (12
fibroblasts and chronic inflammatory cells which seep in joint patients) received ice & P.N.F technique and the fouth group
capsule of the shoulder [7]. The current consensus definition of (8 patients), the no treatment group were taught pendular
the American Shoulder and Elbow Surgeons is: “condition of exercises & instructed to continue every hourly. Their study
uncertain etiology characterized by significant restriction of has shown that there is little long-term advantage in any of the
both active and passive shoulder motion that occurs in the treatment regimens over no treatment, but that steroid
absence of a known intrinsic shoulder disorder” [8, 9]. injections may benefit pain and range of movement in the
AC occurs in 2% to 5% of the population [9]. It is more early stages. There appears to be little place for physiotherapy
frequent in women aged between 40 and 60 years and in alone, and, if used, it should not be continued for more than
about 20–30% of cases this condition is bilateral [11]. four weeks [16].
Frozen shoulder may be considered primary, or idiopathic, In another study Vermeulen et al found that high-grade
when it develops spontaneously, and is considered secondary mobilization technique was more effective than low-grade
when an underlying, precipitating pathologic condition is mobilization technique (within the pain limits) in increasing
present (e.g fracture). mobility and functional ability [17].
Primary frozen shoulder is a unique condition that typically is Johnson et al. compared anterior versus posterior glide
unilateral and rarely recurs in the same shoulder .Subsequent mobilization. They concluded that a posteriorly directed joint
involvement of the contra lateral shoulder occurs in up to 20% mobilization technique was more effective than an anteriorly
of patients. Three classic stages in clinical course of primary directed mobilization technique for improving external
(idiopathic) frozen shoulder have been described: [12] rotation after three treatment sessions [18].
How the best way best to manage patients with adhesive
capsulitis? Exercise Therapy
Different exercises are prescribed to the patients with A.C in
Intervention different phases to increase joint R.O.M, maintain R.O.M,
There are so many methods of physiotherapy for adhesive increase strength of muscles.
capsulitis. Shoulder mobilization, electrotherapy and exercise In a retrospective cohort study by Jewell. D.V. et al, 2370
therapy can be used as treatment. Although the goal of each patients with A.C were given physiotherapy and it has been
treatment is to reduce pain and increase joint R.O.M. Binder found out that both manual shoulder mobilization techniques
et al. found that 50% of patients with frozen shoulders and self-exercise like stretching and home programs are
received no advice from their primary care physicians about effective for the treatment of AC [19].
the need for early shoulder motion [13]. In another study by Tanaka K. et al, Self-exercises twice daily
appeared instead superior than shoulder mobilization by a
Shoulder mobilization physiotherapist twice a week [20].
Shoulder mobilization techniques are graded oscillatory Page M.J. et al, in their RCT “Manual therapy and exercise
techniques widely used in A.C to reduce pain & to increase for adhesive capsulitis (frozen shoulder)” found out that a
joint R.O.M. There are different schools of thought; among combination of manual therapy and exercise may not be as
them Maitland’s mobilization technique is quite popular. effective as glucocorticoid injection in the short-term. Though
M.J. Page et al. performed 32 RCTs with various they have also commented that “High-quality RCTs are
combinations of mobilization, electrotherapy, exercise needed to establish the benefits and harms of manual therapy
therapy and glucocorticoid injections in patients with AC. and exercise interventions that reflect actual practice,
They concluded that a combination of manual therapy and compared with placebo, no intervention and active
exercise may not be as effective as glucocorticoid injection in interventions with evidence of benefit (e.g. glucocorticoid
the short-term. It is unclear whether a combination of manual injection)” [21].
therapy, exercise and electrotherapy is an effective adjunct to Joshua Cleland et al, in review said that many patients treated
glucocorticoid injection or oral NSAID. They also with physical therapy benefited from reduced symptoms,
commented that high-quality RCTs are needed to establish the increased mobility, and/or functional improvement. However,
benefits and harms of manual therapy and exercise poor standardization of terminology, methodology, and
interventions that reflect actual practice, compared with outcome measurements in these investigations undermines
placebo, no intervention and active interventions with their validity and clinical application [22].
evidence of benefit [14]. Positive results have been found out in a case report by
In another study, Anthony Ewald, MD, stated in his research Kathryn H. Blundell. She concluded that a treatment plan
article” Adhesive Capsulitis: A Review” that Physical therapy including comprehensive massage therapy and therapeutic
in conjunction with corticosteroid injections is more effective exercise was effective in providing relief for the symptoms of
than physical therapy alone. Aggressive physical therapy can chronic adhesive capsulitis. This study provides support for
exacerbate pain and diminish adherence to the treatment plan; the effectiveness of massage therapy in treating decreased
therefore, caution should be used in patients who have a high mobility in the glenohumeral joint. She recommended further
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International Journal of Physical Education, Sports and Health

research to clarify the relative contributions of the various and disability index (SPADI), pain visual analogue
components of massage therapy in treatment of this condition scale (VAS), and 3) active/passive range of motion (ROM)
[23]
. were measured before treatment and at 2, 4, 8, and 12 weeks
In a RCT by Kingkaew Pajareya, MD, got better results in the after the treatment. They have found that BVA in combination
group of patients received combination of physiotherapy & with PT can be more effective in improving pain and function
Ibuprofen than the group received only Ibuprofen [24]. than PT alone in AC [37].
In another study by Fusun Guler-Uysal, the group of patients Emad S Tukmachi has applied Chinese acupuncture therapy
treated with Cyriax approach of deep friction massage & in 31 patients with frozen shoulder who previously received
mobilization, got better results that the group received western treatments including physiotherapy in a pilot study.
hotpack & S.W.D as treatment [25]. He has found that acupuncture therapy in frozen shoulder
offers rapid and effective analgesia and reduction of shoulder
Electro Therapy stiffness [38].
Electrotherapy modalities like U.S.T, I.F.T, T.E.N.S, Laser,
S.W.D, are commonly used in A.C to reduce pain & 3. Results & Discussion
inflammation, increase joint R.O.M, increase strength of Results
muscles. Different studies reveal their importance in the It is difficult to draw conclusion about the best physiotherapy
treatment of “Frozen shoulder”. methods in the treatment of adhesive capsulitis of shoulder as
In a study by Green S., L.L.L.T has been found to be effective there are few evidences. Physiotherapy can be applied
than placebo [26]. Page M.J used L.L.L.T & P.E.M.F on more depending upon the stage of the disease & symptoms of the
than twelve hundred patients selected randomly into groups & condition. In the early stage when pain & inflammation is
laser therapy has been found very effective as a treatment [27]. more, main objective should be to reduce inflammation which
Jewell D.V. et al. in a retrospective cohort study used eventually reduce pain & improve the functional status of the
ultrasound, phonophoresis, iontophoresis, mobilization, patient. Here electrotherapy plays an important role. In later
exercises in more than two thousand patients with A.C & stages of the condition where joint stiffness dominates
patients received mobilization & exercises showed better mobilization & manipulation, exercises should be used to
improvement than the other group of patients [28]. improve the range. Overall the need of continuation home
Rizk. T. E. et al demonstrated better results with use of exercise programme, lifestyle modification should be
T.E.N.S & pulley traction than use of therapeutic exercises & explained by the physiotherapist & the patient must include
rhythmic stabilization manipulation techniques [29]. those in their daily routine as “MUST DO”.
In a comparative study by Shahbaz Nawaz Ansari between
U.S.T & end range mobilization and cryotherapy & end range Discussion
mobilizations in frozen shoulder patients, the group of The aim of the study was to provide an evidence based
patients received U.S.T shows better results than the other overview regarding effectiveness of shoulder mobilization,
group [30]. exercise therapy, electro therapy as treatment of adhesive
Leung et al. conducted a RCT which demonstrate that capsulitis of shoulder joint. I have also overviewed recent
addition of deep heating to stretching exercises produces a advances in the treatment of frozen shoulder.
greater improvement in pain relief, and leads to improved Shoulder mobilization techniques are quite popular techniques
performance in daily living activities and in range of motion, used as treatment for frozen shoulder. Few researchers used
more than superficial heating [31]. shoulder mobilization in combination with glucocorticoid
J Hamer et al suggested use of ultrasonic therapy & injections, they concluded that combination of shoulder
cryotherapy is useful in treatment of frozen shoulder as these mobilization, exercise & electrotherapy may not be useful
techniques can improve the painful stage of the condition & in without glucocorticoids or NSAIDS. However they
conjunction with specific exercises, can hasten the recovery recommended high quality trials to prove the hypothesis. In
of range of shoulder movement [32]. another study it has been recommended that aggressive
physiotherapy can increase pain & stiffness of shoulder, so
Recent Advances precautions should be taken before applying these techniques.
In a review on frozen shoulder Wong P.L.K has mentioned Few of the researchers concluded that shoulder mobilization
use of eletroacupuncture combined with shoulder exercises techniques should not be continued for more than four weeks.
for treatment of frozen shoulder [33]. In few studies researchers got positive results after using
In another study by C. Melzer, combination of manipulation shoulder mobilization techniques like high grade mobilization
under anaesthesia & shoulder mobilization proved to be & posterior directed joint mobilizing techniques in frozen
beneficial [34]. shoulder.
J. Vas et al. in a R.C.T got better results in the experimental In my view in these studies, researchers depended mostly on
group received acupuncture than control group received mock drugs for controlling pain & stiffness. They have not used any
T.E.N.S while both groups received physiotherapy [35]. standardized physiotherapy protocol as treatment of AC.
Pamela Teys & Leanne Bisset in a double blind randomized Many of them used combinations of mobilization, exercise &
control trial, applied Mulligan’s movement with mobilization electro therapy with drugs. So I think high quality RCTs
technique (MWM) in 24 patients (13 male & 11 female). needed using a standardized physiotherapy protocol without
They have found improvement in both R.O.M & pressure using pharmacotherapy for longer period of time & in large
pain threshold (PPT) after application of MWM [36]. number of patients. In different studies exercises are used to
Pil Seong Koh et al in a randomized control trial treated improve the joint R.O.M, decrease joint stiffness, increase
patients with frozen shoulder with Bee venom acupuncture muscle strength. Home exercise programme with stretching
(BVA) with other conventional methods of physiotherapy shows good results in AC. Some studies show self exercises
(group 1 & 2) & the third group received normal saline with like Codman’s exercise, capsular self-stretching improved the
other conventional methods of physiotherapy. Shoulder pain condition better than mobilization.
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International Journal of Physical Education, Sports and Health

Glucocorticoid injections with exercises proved to be Electrotherapy modalities are widely used in case of frozen
beneficial in controlling pain & inflammation in short term shoulder to control pain & inflammation, to increase joint
courses, but high quality RCTs needed to prove impact of R.O.M. During comparison, electrotherapy found to be
exercise & mobilization on AC. Many of the researchers used effective more than exercise therapy for pain modulation in
physiotherapy as a supportive treatment, but they have not frozen shoulder patients [39]. In a control trial Morgan et al
maintained standardized methodology. found TENS was well tolerated by the patients with AC. 40
Massage showed positive results over other conventional Some researchers got better results in patients those are
mode of physiotherapy in one of the study. Further research treated with TENS & pulley traction. In some studies deep
recommended clarifying the relative contributions of the heat with stretching showed positive results compared to
various components of massage therapy in treatment of this superficial heating. Cryotherapy in combination with U.S.T
condition. In one of the studies Cyriax approach of deep was able to decrease pain & inflammation in AC.
friction massage & mobilization showed better improvement
over electrotherapy in frozen shoulder patients. 3.1 Tables

Table 1: Stages of Adhesive Capsulitis.

Stages Duration Symptoms
Painful or freezing phase 2-9 months Gradual onset of diffuse shoulder pain, gradual loss of glenohumeral motion.
Stiffening or frozen phase 4-12 months Shoulder movement often restricted in characteristic pattern, with loss of ER, IR, abduction.
Thawing phase Variable time course Gradual regaining of shoulder motion.

4. Conclusions of mobility and stability. Rosemont, IL: American

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