CLINICAL SUGGESTION

NAJSPT ADHESIVE CAPSULITIS: USE THE EVIDENCE

TO INTEGRATE YOUR INTERVENTIONS
Phil Page PhD, PT, ATC, FACSM, CSCS1,2
Andre Labbe PT, MOMT3

ABSTRACT
Frozen shoulder syndrome, clinically known as adhesive capsulitis, is a painful and debilitating condition
affecting up to 5% of the population. Adhesive capsulitis is considered fibrosis of the glenohumeral joint
capsule with a chronic inflammatory response. Patients experience pain, limited range of motion, and dis-
ability generally lasting anywhere from 1 to 24 months. The purpose of this clinical suggestion is to review
the pathophysiolgy of adhesive capsulitis and discuss physical therapy interventions which are supported
by evidence, thereby enhancing evidence-based practice.

Key words: Adhesive capsulitis, physical therapy interventions.

1
Louisiana State University, Department of Kinesiology
2
The Hygenic Corporation
18422 Green Willow Dr.
Baton Rouge, LA 70817
[email protected] CORRESPONDENCE
3
A & K Physical Therapy
New Orleans, LA Phil Page, PhD, PT, ATC
[email protected] [email protected]

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The “frozen shoulder” diagnosis has been used for Frozen shoulder may also be confused with other
many years in describing shoulder pain and limited clinical syndromes; therefore, it is important to have
motion, and was originally thought to be “periarthri- an accurate differential diagnosis to rule out other
tis.” Nevasier was the first to identify the pathology pathologies. For example, chronic regional pain syn-
through histological and surgical examination of fro- drome (CRPS, formerly known as reflex sympathetic
zen shoulder patients.1 He concluded that frozen dystrophy) may cause severe limitations in shoulder
shoulder was not periarthritis, but a “thickening and range of motion similar to those seen with a frozen
contraction of the capsule which becomes adherent shoulder; however, CRPS is also associated with
to the humeral head” that he termed, “adhesive cap- swelling and other trophic skin changes in the
sulitis.”1 Adhesive capsulitis is characterized by pain, extremity. Some have speculated, however, that
stiffness, and limited function of the glenohumeral adhesive capsulitis is in-fact a type of “sympathetic
joint, which adversely affects the entire upper extrem- dystrophy,” based on decreases in bone mineral
ity. Patients typically describe onset of shoulder pain density seen in patients with frozen shoulder.12
followed by a loss of motion.2 The most common lim- Shoulder girdle tumors, although rare, may also
itations in range of motion are flexion, abduction, and mimic the symptoms of frozen shoulder.13
external rotation. Approximately 70% of frozen shoul-
der patients are women;3 however, males with frozen Three stages of frozen shoulder have been described
shoulder are at greater risk for longer recovery and in the literature: painful stage, stiffness or “frozen”
greater disability3-4. Although the exact pathophysio- stage, and recovery or “thawing” stage, with the aver-
logic cause of this pathology remains elusive, there age length of symptoms lasting 30 months.14 The
are two types identified in the literature: idiopathic average range of motion in frozen-stage shoulder
and secondary adhesive capsulitis.5 patients is 98° of abduction, 117° of flexion, 33°
external rotation and 18° of internal rotation with
Idiopathic (“primary”) adhesive capsulitis occurs the shoulder abducted to 90°15. While the “stiffness
spontaneously without a specific precipitating event. stage” is the longest of the stages, adhesive capsulitis
Primary adhesive capsulitis results from a chronic is thought to be reversible in the acute pain stage16.
inflammatory response with fibroblastic prolifera- In addition to limited range of motion, shoulder
tion, which may actually be an abnormal response complex muscle imbalances lead to altered shoulder
from the immune system.6 Secondary adhesive motion. The upper trapezius tends to be more acti-
capsulitis occurs after a shoulder injury or surgery, vated than the lower trapezius, creating an imbal-
or may be associated with another condition such as ance of the scapular stabilizers17 leading to increased
diabetes, rotator cuff injury, cerebrovascular acci- elevation and upward rotation of the scapula during
dent (CVA) or cardiovascular disease, which may elevation of the glenohumeral joint in both the fron-
prolong recovery and limit outcomes.7 In a profile tal and sagittal planes.15,18 Patients with adhesive
study of 32 patients with adhesive capsulitis, heart capsulitis have higher EMG ratios of upper trapezius
disease and diabetes were more prevalent in those to lower trapezius during arm elevation when com-
suffering from adhesive capsulitis than a control pared to asymptomatic subjects, indicating a muscu-
group.2 In a 1986 study, 19% of older diabetic patients lar imbalance.17
had adhesive capsulitis;8 however, recent estimates
place the incidence as high as 71% when patients Patients with frozen shoulder exhibit significant def-
with pre-diabetes (metabolic syndrome) are icits in shoulder kinematics, including increased
included.9 Both Type I and Type II diabetics are sus- elevation and upward scapular rotation.15,19 Eventu-
ceptible to frozen shoulder;10 unfortunately, diabet- ally, patients with adhesive capsulitis develop the
ics have worse functional outcomes as measured by characteristic “shrug sign” during glenohumeral
disability and quality of life questionnaires com- joint elevation, where the scapula migrates upward
pared to non-diabetics with frozen shoulder.4 Frozen prior to 60 degrees of abduction. This indicates com-
shoulder is also a common complication following pensation due to lack of capsular extensibility as
stroke, occurring in 25% of patients within 6 well as a change in the central nervous system motor
months.11 patterning due to maladaptive movement. Patients

North American Journal of Sports Physical Therapy | Volume 5, Number 4 | December 2010 | Page 267
with adhesive capsulitis may also develop adaptive adhesive capsulitis, it is important to remember that
postural deviations such as anterior shoulders or not all clinical interventions have evidence to sup-
increased thoracic kyphosis as the function of the port their use in specific patient populations. Recall
shoulder complex remains limited and painful. that evidence-based practice is best defined as the
use of the best evidence available along with clinical
Adhesive capsulitis is generally related to a shorten- experience while taking into consideration the
ing and fibrosis of the joint capsule (ligaments) sur- unique needs of an individual patient.
rounding the shoulder joint. Nevasier1 was among
the first to report thickening and contraction of the Modalities. The rationale for using modalities in
shoulder capsule as well as inflammatory changes patients with adhesive capsulitis includes pain relief
through histologic analysis. The contracture of the and affecting scar tissue (collagen). However, the use
shoulder ligaments actually decreases the volume of of modalities such as ultrasound, massage, iontopho-
the capsule, thus limiting range of motion. It is likely resis, and phonophoresis has not been proven to be
that limitations in range of motion and the pain beneficial in treatment of patients with adhesive cap-
associated with frozen shoulder are not only related sulitis.25,27 Interestingly, transcutaneous electrical
to capsular and ligamentous tightness, but also fas- stimulation (TENS) has been shown to significantly
cial restrictions, muscular tightness, and trigger increase range of motion more than heat combined
points within the muscles. Physical therapists can with exercise and manipulation.28 Research also sug-
address impairments and limitations associated gests that low-power laser therapy is more effective
each of these contributors to the pathology of adhe- than a placebo for treatment of patients with adhe-
sive capsultis with a variety of treatment methods. sive capsulitis.29-30 Recently, deep heating through dia-
thermy combined with stretching was shown to be
PHYSICAL THERAPY INTERVENTIONS more effective than superficial heating for treating
Levine and colleagues20 showed a 90% success rate frozen shoulder patients.31
with non-operative treatment (oral NSAIDs and Passive Motion. Because adhesive capsulitis involves
standardized physical therapy) over an average of 4 fibrotic changes to the capsuloligamentous structures,
months. As little as 4 weeks of targeted intervention continuous passive motion or dynamic splinting are
can improve pain and strength in frozen shoulder thought to help elongate collagen fibers. Continuous
patients 21-22. It has been suggested23 that ‘gentle’ passive motion (CPM) was recently compared with
therapy (painfree pendulum and active exercises) is conventional PT in 57 patients with adhesive capsuli-
better than ‘intensive’ therapy (passive stretching tis.32 Both groups improved after 4 weeks of treat-
and manipulation up to and beyond the pain thresh- ment; while there was no significant difference
old). Unfortunately, frozen shoulder patients often between the groups, the CPM patients had greater
maintain some deficiencies in range of motion even reduction in pain levels. Dynamic splinting was also
after ‘successful’ treatment.4 In a 15 year follow-up, recently evaluated in patients with Stage 2 (“frozen
Farrell24 reported forward elevation range of motion stage”) adhesive capsulitis.33 The authors, Gaspar and
of only 168° and external rotation of 67°. Willis, noted better outcomes when physical therapy
was combined with the Dynasplint® protocol,
Jewell and colleagues25 suggested in their meta-
although there was no statistically significant differ-
analysis of physical therapy interventions for frozen
ence between standard physical therapy or the
shoulder syndrome that joint mobilization and exer-
Dynasplint alone. The concept of total end-range
cise were the most effective interventions. Non-
time (TERT) has also been described in the treatment
aggressive physical therapy interventions are
of patients with adhesive capsulitis, suggesting main-
generally more effective than aggressive or inten-
tenance of a stretch in the maximally lengthened
sive interventions23,26. Physical therapy interven-
range of motion for a total of 60 minutes per day 34-35.
tions used with patients with frozen shoulder
frequently include modalities, manual techniques, Manual Techniques. As stated previously, joint
and therapeutic exercise. While some of these inter- mobilization is an effective intervention for adhe-
ventions have been studied in patients with sive capsulitis. Several studies have demonstrated

North American Journal of Sports Physical Therapy | Volume 5, Number 4 | December 2010 | Page 268
 Figure 2: Instrument-assisted Graston Technique® for treat-
ment of the pectoral fascia. (Used with permission, Graston
Technique®).

present in the musculature around the shoulder com-

plex in patients with adhesive capsulitis.38 In Travel
and Simons’ classic textbook, the authors describe
how the subscapularis muscle in particular is referred
to as the “Frozen Shoulder” muscle because trigger
points in the subscapularis cause limitations in shoul-
der elevation and external rotation.39 The Spray and
Figure 1: Spray and Stretch® technique for treatment of the
Stretch® technique for the subscapularis and latissi-
subscapularis. (Copyright, Gebauer Company, used with per-
mission.) mus dorsi muscle may be effective at reducing trigger
point irritation, pain, and helping to gradually
lengthen tight muscles.40 (Figure 1)
the effectiveness of joint mobilization in adhesive
capsulitis patients.25,36-37 In particular, posterior glide Soft Tissue Mobilization. Soft tissue mobilization
mobilization was determined to be more effective and deep friction massage may benefit adhesive
than anterior glide for improving external rotation capsulitis patients. Deep friction massage using the
range of motion in patients with adhesive capsuli- Cyriax method was shown to be superior to superfi-
tis36 Johnson and colleagues randomly assigned 20 cial heat and diathermy in treatment of patients
consecutive adhesive capsulitis patients to physical with adhesive capsulitis.41 Recently, instrument-
therapy intervention including grade III stretch assisted soft tissue mobilization (IASTM) as used in
mobilization with distraction at end range of abduc- such interventions as Graston Technique®, ASTYM®,
tion and external rotation using either an anterior or or guasha has become increasingly popular in physi-
posterior directed linear translation. After 3 ses- cal therapy practice. IASTM reportedly provides
sions, the posterior mobilization group had signifi- strong afferent stimulation and reorganization of
cantly improved their external rotation range of collagen, as well as in increase in microcirculation.
motion by 31 degrees versus only 3 degrees in the The inferior glenohumeral capsule and pectoral fas-
anterior mobilization group. In addition, high-grade cia are often restricted, as well as the insertion of the
joint mobilization techniques were more effective latissimus dorsi and subscapularis. IASTM may help
than low-grade mobilization in improving glenohu- improve fibroblast proliferation and promote nor-
meral mobility and reducing disability in a recent mal collagen alignment,42-43 although no studies have
randomized controlled trial of treatment of patients evaluated outcomes of the use of IASTM on patients
with adhesive capsulitis.37 with adhesive capsulitis. (Figure 2)
As discussed earlier, myofascial trigger points, focal Therapeutic Exercise. Probably the most commonly
areas of increased tension within a muscle, may be prescribed therapeutic exercises for adhesive capsulitis

North American Journal of Sports Physical Therapy | Volume 5, Number 4 | December 2010 | Page 269
are active-assisted range of motion (AAROM) exer-
cises. These typically involve the patient using the
uninvolved arm, or using equipment such as rope-
and-pulley, wand/T-bar, or exercise balls. Generally,
these exercises are performed for flexion, abduction
and external rotation ranges of motion which are
frequently the most limited. Griggs and colleagues
found that physical therapy including 4 self-stretches
(passive flexion, horizontal adduction, internal rota-
tion behind the back with the unaffected arm, and
external rotation at 0° using a cane) performed at
least twice a day produced a satisfactory outcome in
90 percent of stage 2 adhesive capsulitis patients.4
These patients significantly improved in pain, range
of motion, and shoulder function; however, the
study did not compare the intervention to other
types of treatment. Despite this limitation, the
authors suggested that more aggressive treatments
such as manipulation are rarely necessary.
Resistive exercises typically include strengthening
of the scapular stabilizers and rotator cuff, when
range of motion has progressed enough for strength-
ening to be an appropriate intervention. Muscles
prone to weakness in a variety of shoulder dysfunc-
tions include the lower trapezius, serratus anterior,
and infraspinatus. Patients with adhesive capsulitis
have significantly weaker lower trapezius muscles
compared to asymptomatic controls.17 It is impor-
tant that treating therapists facilitate normal move-
ment patterns rather than allowing pathological Figure 3: “Shoulder Sling” exercise designed to facilitate “set-
adaptive patterns to prevail during movement for ting” of the rotator cuff. Place an elastic loop under the elbow
the sake of completing an exercise. For example, if a and around the neck and opposite shoulder. Simultaneously
depress your shoulder and initiate abduction against the
patient demonstrates a ‘shrug sign’ while perform-
band resistance, pushing your elbow in a “down and out”
ing resisted abduction, the exercise should be motion. Do not actually move the arm away from the body.
stopped and modified with less resistance or be (Used with permission, The Hygenic Corporation).
attempted in an altered position, while cuing of the
patient for proper movement patterns. The “Shoul-
der Sling” exercise can be used to help re-train the
this exercise helps reduce early activation of the
initial setting phase of the rotator cuff when initiat-
upper trapezius during abduction in patients dem-
ing abduction. (Figure 3) The Shoulder Sling exer-
onstrating a shrug sign.
cise for a “rotator cuff set” is considered analogous to
a “quad set” exercise in the lower extremity. The Rigid and Kinesiological Taping. Although no studies
elastic band creates an “upward and inward” vector have been published on the efficacy of taping (such
of resistance that the patient must push against in a as rigid strapping tape or kinesiological taping [KT])
“down and out” vector. This movement simulates with patients who have adhesive capsulitis, taping
the initiation of abduction as well as the depression may be helpful in reducing pain and providing tac-
and stabilization functions of the rotator cuff, which tile cues through proprioceptive and afferent mech-
occur prior to and during abduction. Anecdotally, anisms. The mechanisms and efficacy of taping

North American Journal of Sports Physical Therapy | Volume 5, Number 4 | December 2010 | Page 270
 ranges of motion, breaking the adhesions located
within of the shoulder capsule. In addition to
increased risk of complications from anesthesia,
MUA can cause severe damage including labral
tears, tendon tears, fractures, and ruptures of the
shoulder ligaments.55 Most recently, steroid injec-
tions with distention arthrography have been shown
to be as effective as MUA and are therefore the rec-
ommended course of treatment because of the risks
associated with MUA.56

In conclusion, adhesive capsulitis is a challenging

condition for both the physical therapist and patient.
It is important for clinicians to make an accurate
Figure 4: Kinesiological Taping Technique: Postural Spider diagnosis and assessment in order to best choose
(Used with permission, SpiderTech). their interventions. By understanding the published
evidence related to the rehabilitation of patients
applications remain unclear. Because adhesive capsu- with adhesive capsulitis, both therapists and patients
litis patients often exhibit poor posture and scapular will benefit from an integrated, multi-faceted, evi-
mechanics, KT may provide postural cues and assist dence-based approach to intervention.
with promoting proper scapular motion. (Figure 4)
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