ADHESIVE CAPSULITIS

also referred to as frozen shoulder, an intracapsular inflammation

is a musculoskeletal condition that has a disabling capability (Article_9031.pdf)
painful restriction in shoulder range of motion in a patient with normal radiographs.
(Braddom)
- is an abnormality that develops gradually with increasing pain and decreasing range of
motion.
- is a painful and disabling disorder of unclear cause in which the shoulder capsule the
connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed
and stiff, greatly restricting motion and causing chronic pain. (en.m.wikipedia.org)
- An idiopathic condition but it can be associated with diabetes mellitus or inflammatory
arthritis
- Neviaser describes adhesive capsulitis as a distinct entity with four identifiable stages
that are arthroscopically distinct. (see Stages of Adhesive Capsulitis)
I. DEFINITION OF TERMS
-

Idiopathic
- relating to or denoting any disease or condition that arises spontaneously or for
which the cause is unknown
- primary adhesive capsulitis is idiopathic in nature and radiographs appear normal
(BWH_case_presentation.pdf)
Joint Stiffness
- may be a symptom of pain on moving a joint, loss of range of motion or the physical
sign of reduced range of motion. (En.m.wikipedia.org)
- it is one of the most pervasive sign or symptom of frozen shoulder
(www.medicalnewstoday.com)
Immobilization
- fixation (as by a plaster cast) of a body part usually to promote healing the in normal
structural relation. (Merriam Medical Dictionary)
- prolonged immobilization (due to a surgery, recent injury or period of surgery)
following one of these injuries (trauma, tendonitis, or tears) is a significant risk factor
adhesive capsulitis. (DeLisa)
Range of Motion (ROM)
- amount of angular motion allowed at the joint between any two boney levers (Kisner)
- decreased ROM is one of the hallmark of adhesive capsulitis. (www.aafp.org)
Capsular Pattern
- pattern of limitation, characteristic for a given joint, that indicates a problem exists
with that joint (Kisner)
- distinct capsular pattern of stiffness in patients with frozen shoulder:
o Lateral Rotation>Flexion>Internal Rotation. (physioworks.com.au)
Diabetes Mellitus
- the most common form of diabetes, caused by a deficiency of the pancreatic
hormone insulin, which results in a failure to metabolize sugars and starch.
- its the most common risk factor of adhesive capsulitis.

Classification of Adhesive Capsulitis (Lunberg)

Primary Frozen Shoulder

- shoulder elevation is less than 135o
- limitation of movement only at glenohumeral articulation
- normal in radiographic examination
Secondary Frozen Shoulder
- decreased range of motion following trauma or other known cause
Stages of Adhesive Capsulitis

Stage 1 (Pre-Freezing)
- occurs for the first 1 - 3 months and involves pain with shoulder movements but no
significant glenohumeral joint ROM restriction when examined under anesthesia,
however, there is diffuse synovitis especially in the anterosuperior shoulder capsule.
- pain is seen with active and passive range of motion.
- external rotation activities are particularly sensitive. There is limitation of forward
flexion, abduction, internal rotation and external rotation.
Stage 2 (Freezing Stage)
- symptoms have been present for 3 - 9 months and are characterized by pain with
shoulder motion and progressive glenohumeral joint ROM restriction in forward
flexion, abduction, and internal and external rotation.
- There is true, significant limitation of motion in all planes.
- Inside the shoulder there is diffuse hypertrophic, hypervascular synovitis and
thickening of the capsule.
Stage 3 (Frozen Stage)
have been present for 9 - 15 months and include a significant reduction in pain but
maintenance of the restricted glenohumeral joint ROM.
- There is significant limitation of range of motion with a rigid endpoint.
- Inside the shoulder the hypervascularity is absent but the shoulder capsule is
thickened and the volume of the shoulder is decreased.
Stage 4 (Thawing Stage)
- the symptoms have been present for approximately 15 - 24 months and ROM
gradually improves.
Conventional Classification

Acute Stage
- is characterized by pain on lateral brachial region, more in the night.
- has restriction of ROM due to pain and spasm.
Chronic Stage
- is characterized by absence of rest pain and night pain.
- pain become localized only in lateral brachial region.
- pain is experienced during activities due to stretching of tight joint capsule.
- has movements restricted in capsular pattern with leathery end feel.

II. EPIDEMIOLOGY

Incidence: Adhesive capsulitis occurs in ~2% to 5% of the general population

(Braddom)

Age: Usually occurs between the ages of 40 and 60 years (Braddom)

Sex: Adhesive capsulitis is 2 to 4 times more common in women than men (Braddom)

Lifestyle: Work-sedentary workers are commonly affected than laborers

Laterality: It usually affects the non-dominant shoulder although it can occur in either
shoulder. Bilateral frozen shoulder occurs in around 14% of patients (patient.info)

Inheritance: There is no known genetic or racial predilection

Conditions: Common in persons with insulin-dependent and non-insulin-dependent

diabetes, and in those with prediabetes (glucose intolerance)

Reoccurrence: An individual with adhesive capsulitis has a 5-34% chance of having it in

the contralateral shoulder at some point in time. (http://www.physio-pedia.com)

III. ANATOMY, PHYSIOLOGY AND KINESIOLOGY

SHOULDER
ANATOMY/ PHYSIOLOGY/ KINESIOLOGY
The limited contact between the large humeral head and a smaller shallow glenoid fossa,
secured only by fibrous capsule and overlying musculocutaneous rotator cuff. (Rowe, C).
A movable base of humeral head
-

As the arm is raised to complete elevation, glenoid fossa smoothly and effectively
positions itself beneath the humeral head for increased mechanical stability.

Synchronous teamwork: entire shoulder girdle, acromioclavicular, sternoclavicular,

scapulothoracic joints.

Recoil mechanism
-

The glide of the scapula along the chest wall absorbs the impact to the shoulder from
falls, direct indirect blows to the shoulder, as well as strain of forceful pushing, pilling, &
lifting.

Compensatory motion
-

Shoulder possesses subtle adjustments for loss of motion of one of its four joints.
Ex. Glenohumeral motion is lost, the scapula supplies needed motion by glide and
rotation along the chest wall, to allow elevation of the arm to the head or above, as well
as sliding motion in adduction and abduction.

Capsule
-

A stable shoulder must have a strong adjustable capsule, particularly in positions of

elevation. In position the rotator cuff muscles glide upward, leaving protected the inferior
capsule ligament. With avulsion of the capsule from the glenoid rim, or excess laxity of
the capsule, stability of the shoulder is lost.

MECHANICAL STRUCTURE
Mobility
The most mobile joint is the junction of the humerus and scapula. Vastdimensional mobility is provided by the skeletal characteristics of the articulation.
The humeral articular surface is a superior-medially oriented hemisphere. The
dominance of mobility over stability is even evident on the arms resting posture.
Resting Alignment
The functional resting posture of the shoulder places the arm at the side of the
body. With the subject standing, the arm is dependent and the humerus is
grossly vertical.
Within the scapula, the significant alignment of the glenohumeral joint is the
plane of the glenoid fossa.
Motion
Shoulder mobility is classified by three patterns of motion: elevation,
internal/external rotation, and horizontal flexion and extension.
Elevation
a. Raising the arm from the side of the body to its peak overhead position is a
theoretical 180 degrees arc.

b. Arm elevation is a complex action that is best analyzed as three functional

modes: Planes of motion, Scapulohumeral Rhythm, and Centers of rotation.
Planes of Motion
Neutral elevation of the arm occurs in the plane of the scapula. This is angled approximately 30
degrees anterior to the bodys coronal plane. Exact alignment is determined by the contour of
the thoracic wall on which the scapula rests.
This alignment of the glenoid fossa is matched by 30 degrees retroversion of the head of the
humerus on its shaft. Hence glenohumeral joint is designed to follow plane of the scapula. As
the arm is raised in the scapular plane, the path of the humerus is perpendicular to the face of
the glenoid: the joint is in neutral alignment.
1. Flexion is sagittal plane elevation. Placing the arm in this plane includes significant
horizontal flexion. Hence, the path of the humerus is oblique to the face of scapula.
The inferior joint capsule twists to accommodate this path of arm elevation.
2. Abduction raises the arm on the coronal plane. This introduces two limitations.
a. An element of horizontal extension is included in the elevation motion.
b. More significant is the potential for impingement of the greater tuberosity against
the acromion since normal clearance is so minimal that there is no space for
tendon thickening.
This can be avoided by adding external rotation to the abduction motion.
Scapulohumeral Rhythm
Total arm elevation is the sum of motion at two areas: The glenohumeral joint and gliding of the
scapula on the thorax. In gross terms the ratio is 2:1 but more precise analysis has shown
considerable variability.
At the onset of arm elevation, scapular participation has proved to be highly variable. It may be
absent, minimal, or even reversed. This lag in scapular motion persisted through the first 60
degrees of flexion and 30 degrees abduction.
Once the scapula started to participate, both segments the humerus and scapula moved
continuously and synchronously. Hence, there is approximately 3 degrees of glenohumeral
motion for each 2 degrees occurring at the scapula.

Dividing the total arc into segments helps to identify inconstant rate of motion for both bones. Of
particular significance was a relative slowing in scapular motion in the terminal arc (120 degrees
to maximum).
Instant Centers of Motion
Each joint has its own pattern of motion. This is defined by its path of instant centers.
Excursion of the humeral head on the glenoid has been described as both gliding and rolling.
The axis of glenohumeral joint rotation also is quite consistent. Calculation of the instant centers
for each 30 degrees arc of arm elevation placed these points within 5 mm of center of the
humeral head. Hence, the glenohumeral joint acts as true ball and socket.
The scapula was found to follow a more complex path of motion. During its initial setting stage
(its first 60 degrees), either there was no motion or the scapula joggled around a center of
rotation in the lower part of the blade. Subsequent scapular rotation was grossly centered near
to the base of the scapular spine until the arm reaches 120 degrees.
Axial Rotation
Internal and external rotation of the arm is a function of the glenohumeral joints. Due to change
in relative capsule length, the range varies with arm position.
Maximum rotation of approximately 180 degrees is present with the arm at the side of the body
(adducted). The larger portion of the range of 108 degrees or 60% is external rotation.
Abduction of the arm to 90 degrees reduces the total arc to 120 degrees.
Within this range there is more internal than external rotation.
Horizontal Flexion/Extension
These motions also have been called Horizontal adduction/abduction. Within the normal 180
degrees arc, only 45 degrees or 24% is horizontal extension behind the coronal plan. Most of
the motion is Glenohumeral. The limitation of this motion is the edge of the humeral articular
surface.
Scapular rotation also is reflected by the path of the coracoid, while the acromion
remains relatively fixed.

Functional Anatomy
Shoulder Girdle Complex
1. Glenohumeral
2. Acromiohumeral
3. Sternoclavicular
4. Acromioclavicular
5. Scapulothoracic

1. Glenohumeral joint
(Myers et al)
-

ball & socket

relationship

Humeral head is LARGER than the glenoid (incongruous joint)

Head & shaft of humerus: vary from angle of 130o to 150o

**Significance of retroversion of humeral head: hides the joint from palpation by placing
greater tuberosity more anteriorly
Glenoid fossa: 5o superior tilt & 7o retroverted
Humeral condyles: 30o (posterior/ retroverted to the elbow)

Scaption elevation in the path of least resistance would be along coronal plane

Glenoid fossa surface contact is 1/3 to the size of humeral head leading to increase
mobility at the expense of stability. (Myers et al)
-

Ligaments:
Closely related to the capsule and attached to the upper & middle part of the medial
margin of the glenoid cavity, blending to labrum.
Superior ligament: descents & parallel to the bicipital tendon, attaching to a small
depression above the lesser tuberosity of the humerus & base of coracoid process;
limiting inferior translation in adduction
Middle ligament: from superior glenohumeral ligament & part of glenoid rim attaching to
anterior aspect of the anatomical neck of the humerus lying underneath the tendon of
the subscapularis muscle; limits lateral rotation between 45o & 90o abduction
Inferior ligament: thickest of all three; attaches to anterior, inferior, & posterior margin
of glenoid labrum to
inferior aspect of humeral
head; divided into 2
bands (superior &
inferior) referred to as
axillary pouch of inferior
glenohumeral ligament; it
supports the humeral
head above 90o
abduction limiting inferior
translation while anterior band tightens on lateral rotation and the posterior band tightens
on medial rotation

Bursae
Subdeltoidsubacromial bursae are
collectively referred to as the
subacromial bursa because they are
often continuous innature. The
subacromial bursa is one of the largest
bursae in the body and provides two
smooth serosal layers: (1) adheres to
the overlying deltoid muscle & (2) to the

rotator cuff lying beneath; This bursa is also connected to the acromion, greater
tuberosity, and coracoacromial ligament. As the humerus elevates, it permits the rotator
cuff to slide easily beneath the deltoid muscle.
Smaller bursae: interposed between most of the muscles in contact with the joint
capsule
Subcoracoid bursa this bursa is located under the coracoid process
Subscapular bursa this bursa is located between the subscapular muscle
tendon and the anterior neck of the scapula and protects the tendon as it passes
under the coracoid process
-

Close-Packed Position
Full abduction and ER

Open-Packed Position
Without IR or ER occurring, the open-packed position of the G-H joint has traditionally
been cited as 55o of semi abduction and 30 degrees of horizontal adduction.

Capsular Pattern
According to Cyriax, the capsular pattern for the G-H joint is that ER is the most limited,
abduction the next most limited, and IR the least limited in a 3:2:1 ratio, respectively.

Classification of Glenohumeral Painful Arcs

Night pain
Age
Sex ratio
Aggravated by
Tenderness

Acromioclavicular
joint involvement
Calcification (if
present)
Third-degree strain
biceps

Anterior
Yes
50+
F>M
Lateral rotation and
abduction
Lesser tuberosity

Superior
Maybe
40+
M>F
Abduction

No

Posterior
Yes
50+
F>M
Medial rotation
and abduction
Posterior
aspects of
greater
tuberosity
No

Supraspinatus,
infraspinatus, and/or
subscapularis
No

Supraspinatus
and/or
infraspinatus
No

Supraspinatus
and/or
subscapularis
Occasional

Greater
tuberosity

Often

2. Acromiohumeral joint (Subacromial Space)

-

specified space described by its bony & ligamentous borders

averages 1011 mm in height with the arm adducted to the side. Elevating the arm
decreases this space, and the space is at its narrowest between 60 and 120 degrees of
scaption

Borders
Inferior border: superior aspect of humerus
Superior & Posterior border: acromion

Structures

Most Inferior: synovium & joint capsule of glenohumeral joint with sliding intraarticular biceps tendon within it

Rotator Cuff Muscles: located above the glenohumeral & coracohumeral

ligaments
Attaches to the greater tuberosity

Supraspinatus

Infraspinatus

Teres minor
Attaches to the lesser tuberosity

Subscapularis

Coracoacromial Arch: formed by the

anteroinferior aspect of the acromion
process, and the coracoacromial
ligament, which connects the coracoid
to the acromion and the inferior
surface of the A-C joint.

Acromion
-

Variation in acromion shape

correlated with tears of the rotator
cuff (Bigliani et al)
a. Type I flat
b. Type II smooth cuved

c. Type III hooked (higher frequency of complete rotator cuff tear)

3. Sternoclavicular joint (Brunnstrom et al & Dutton et al)

-

If held vertically, the proximal end of the clavicle is convex whereas the manubrium
surface is concave

Articular disc
The fibrocartilaginous articular disc lies between the two joint surfaces, attaching
inferiorly near the lateral aspect of the clavicular facet on the sternums manubrium.
Superiorly, it attaches to the clavicular head and interclavicular ligament.
This arrangement allows motion to take place both between the clavicle and the disc and
between the disc and the sternum
The disc also increases stability by increasing congruency between the joint surfaces
and provides reduced joint stresses by improving shock absorbency.

Ligaments
Superior sternoclavicular ligament traverses over the superior aspect of the jugular
notch to form the interclavicular ligament; this ligament prevents upward clavicular
displacement at the SC joint
Costoclavicular ligament ligament attaching the clavicle to the first rib; restricts
clavicular elevation, rotation, and medial and lateral movements
Two heads:
1. anterior fibers first rib lie in a superior and lateral direction
2. posterior fibers traverse and angle from the first rib to the clavicle in a superior
and medial direction

Close-Packed Position: The close-packed position for the S-C joint is maximum arm
elevation and protraction.

Open-Packed Position: The open-packed position for the S-C joint has yet to be
determined, but is likely to be when the arm is by the side.

Capsular Pattern: the S-C joint is not controlled by muscles and therefore lacks a
specic capsular pattern. One possibility, seen clinically, is pain at the extreme ranges of
motion, especially full arm elevation and horizontal adduction.

4. Acromioclavicular Joint
-

plane synovial joint with three degrees of freedom involving the medial margin of the
acromion and the lateral end of the clavicle.

The acromial end faces medially and slightly superiorly while the clavicular end faces
laterally and slightly inferiorly to form a wedge-like surface

they are most often flat, so roll and slide arthrokinematics do not occur at this joint.

they are lined with fibrocartilage

Ligaments:
Superior and inferior
acromioclavicular ligaments: reinforce
the joint capsule. This joint binds the
scapula with the clavicle so the two
structures have similar motions; at the
same time, individual accommodation of
each of the bones occurs so subtle

movements of each of these bones can transpire.

Coracoclavicular ligament (conoid and trapezoid portions): primary support for the
A-C joint; from the coracoid process to the inferior surface of the clavicle.
Conoid ligament: is fan shaped with its apex pointing inferiorly. It lies in the
frontal plane and is the more medial of the two ligaments. This ligament functions
to block coracoid movement away from the clavicle inferiorly.
Trapezoid ligament: arises from the medial border of the upper surface of the
coracoid process and runs superiorly and laterally to insert into the inferior
surface of the clavicle. It is larger, longer, and stronger than the conoid and forms
a quadrilateral sheet that lies in a plane that is at right angles to the plane formed
by the conoid ligament. The function of this ligament is unclear, although its
orientation suggests that it may block medial movement of the coracoid or act as
a restraint to superior or posterior displacement of the clavicle. In addition, as the
clavicle rotates upward, the coracoclavicular ligament dictates scapulothoracic
rotation by virtue of its attachment to the scapula.
-

Capsular Pattern: Joints such as the A-C joint, which are not controlled by muscles,
lack true capsular patterns. However, anecdotal clinical evidence suggests that the
capsular pattern for the A-C joint is pain at the extremes of ROM, especially horizontal
adduction and full elevation.

Close-Packed Position: only achievable in the below-30 age group and clinically
seems to correspond to 90o of G-H joint abduction.

Open-Packed Position: The open-packed position for this joint is undetermined,

although it is likely to be when the arm is by the side. This positions the clavicle in
approximately 1520o of retraction relative to the coronal plane and elevated
approximately 2o from the horizontal plane.
5. Scapulothoracic Joint

this is not a true joint because there are no bony articulations, the moving surfaces are
called a false joint, a pseudo joint, or a functional joint.

Relationship of scapula to thorax: lies 30o to 45o angle to the coronal plane

Separating the scapula from the thorax are soft tissue structures, including a large
subscapular bursa.

The serratus anterior muscle attaches to the medial border of the scapula and passes
under the scapula to attach on the anterolateral border of the first nine ribs. A large
amount of motion occurs between the fascia of the muscle and the fascia of the thorax.

Scapulothoracic Joint Function: Normal function of the scapulothoracic joint is

essential for the mobility and stability of the upper extremity. Motion of the
scapulothoracic joint provides a movable base for the humerus and thereby provides
several important functions:
(1)Increasing the range of motion of the shoulder to provide greater reach
(2)Maintaining favorable length-tension relationships for the deltoid muscle to
function above 90 of glenohumeral elevation to allow better shoulder joint stability
throughout a greater motion
(3)Providing glenohumeral stability through maintained glenoid and humeral head
alignment for work in the overhead position
(4)Providing for injury prevention through shock absorption of forces applied to the
outstretched arm
(5)Permitting elevation of the body in activities such as walking with crutches or
performing seated push-ups during transfers by persons with a disability such as
paraplegia.

Close-Packed and Capsular Pattern: Since the scapulothoracic joint is not a true joint,
it does not have a close-packed position or a capsular pattern.

Open-Packed Position: Relative to the thorax, when the arm is by the side, the scapula
is in an average of 30o45o of IR, and slight upward rotation, and approximately 5o20o
degrees of anterior tipping.

Bursae: There are a number of bursae located in and around the scapulothoracic
articulation.
Scapulothoracic bursa: is located between the thoracic cage and the deep surface of
the serratus anterior.
Subscapular bursa: is most often located between the supercial surface of the
serratus anterior and the subscapularis.
Scapulotrapezial bursa: lies between the middle and lower trapezius bers and the
superomedial scapula. The purpose and clinical signicance of the scapulotrapezial
bursa are not known. It may encourage smooth gliding of the superomedial angle of the
scapula against the undersurface of the trapezius during scapular rotation in the same
manner that the scapulothoracic bursa (between the serratus attachment at the

anteromedial surface of the superior angle) encourages smooth gliding against the
underlying ribs.

OTHERS:
A. Joint Capsule
-

attaches to the glenoid rim and the anatomical neck of the humerus

loose anteriorly & inferiorly; tight superiorly

**this slack of the capsule allows for normal distraction of the humeral head from glenoid
fossa for ~1 inches
**Sulcus sign- indication of inferior stability (glenohumeral space: >1inches)

immobilization of shoulder will lead to periarticular changes leading to pain and

significant decrease in mobility of the joint

The capsule can also be a stabilizer (anteriorly): if restricted, it can limit flexion &
external rotation

B. Glenoid labrum
-

add to stability to the stability of the stability of the glenohumeral joint by deepening the
articular surface of glenoid.
**therefore, trauma or pathology to this can lead to instability

made of fibrous connective tissue that is ligamentous in nature, has small band of
fibrocartilage in the transition zone with articular cartilage covering the joint surface

inner surface of the labrum: synovium; outer surface: continuous with periosteum of
scapular neck

superior part of labrum: inserts directly into the biceps tendon (explains the tenderness
experience during palpation in bicipital groove)

the direction of the injury will determine which part of the labrum is torn

labral tear: mostly occur in anterosuperior quadrant (flap tear) of the glenoid that is
cause by traction injury of biceps tendon **a.k.a SLAP lesion

C. Coracohumeral ligament
-

Broad band that strengthens the superior anterior aspect of the capsule

Runs from base & lateral boarder of coracoid process; passes obliquely downward &
laterally to front of greater tuberosity; blending with supraspinatus muscle & capsule

Because of its anterior orientation to the axis of rotation, it also checks lateral rotation
and extension.

D. Rotator Cuff
a. Supraspinatus:
b. Subscapularis
c. Infraspinatus
d. Teres minor

E. Bicipital tendon sheath

-

The long head of the biceps arises from the superior glenoid tubercle and crosses the
head of humerus down the bicipital groove. It doubles back itself to ensheath the tendon

Provides gliding surface by using synovial lining of the capsule and decreases stress in
its articular course

BIOMECHANICS (by: Myers & Brunnstrom)

a.

Scapulohumeral rhythm

- Poppen & Walker: 2:1 ratio of glenohumeral motion to scapulothoracic motion

- Primary dependent on: sternoclavicular & acromioclavicular joint
- Force Couple: develops between trapezius & serratus anterior muscles (upwardly rotates the
scapula)
Sequence of Events: by Norkin & Levangie
1. Phase one - upward rotation force on scapula: upper & lower portion of trapezius muscle
force couple with upper & lower of serratus anterior. As movement increase, place force on
clavicle producing elevation ~90 to 100 degrees
2. Phase two - trapezius & serratus muscle continue to pull generating upward rotation force on
scapula. Rotation is taken up by clavivle rotating on its own axis. Total clavicular elevation
(Inman et al) was 20 degrees occurring in firts 30 & last 45 degrees of shoulder elevation.
Sternoclavicular joint was 40 degrees occurring in 90 degrees of elevation.

b.

Rotator cuff

- not only provides rotational force at humerus but also adds compression to glenoid fossa.
Supraspinatus: provides dynamic stability but can also function as primary abduction
Infraspinatus & Teres minor: provides external rotation of humerus
Subscapularis: same function of dynamic stability of infraspinatus & teres minor but but also
important for preventing anterior shoulder dislocation
c.

Scapulo stabilizer

- 2 force couple in shoulder:

1. Upper trapezius & upper serratus anterior muscle - elevates the arm with upward rotation of
scapula
2. Lower trapezius & lower serratus anterior muscle - acts as synergist, contrlling winging and
allowing for distal segment of scapula to remain contact to thoracic cage.
- Trapezius: more critical for abduction; serratus anterior: flexion. Both muscles act as stabilizer
for deltoid allowing arm to elevate on scapula (the fixed segment)
Middle trapezius & rhomboid muscles: critical to stabilizing the scapula through eccentric
control
Latissimus dorsi & pectoralis muscle: fix scapula to thoracic cage, providing stability for arm
movement.

d.

Muscles of the Shoulder Complex

The shoulder is unique in that its stability during motion occurs not only from ligaments that
restrict terminal motions, but also from muscles that simultaneously provide motion to the same
joints they are stabilizing. Although other joints also rely on muscles for stabilization, very few
use the same muscles that are stabilizing to also serve as movers at the same time. The
muscles of the shoulder girdle also participate significantly in skilled movements of the upper
extremity, such as writing, and are essential in activities requiring pulling, pushing, and throwing,
to mention only a few of the important activities of the upper extremity. The shoulder region
muscles are divided into three groups for study:
1) scapular stabilizers of the shoulder complex
2) glenohumeral stabilizers of the shoulder complex
3) large movers of the shoulder.

1) Scapular Stabilizer Muscles of the Shoulder Complex

-

These muscles are primarily responsible for movement and stabilization of the scapula
during glenohumeral joint motion. They each originate on the thorax and end on the
scapula.

Serratus Anterior

Since it is the primary scapular protractor, without it, the arm cannot be raised overhead.

It is called the saw muscle because of its serrated-looking insertions on the ribs and
thorax. The lowest four or five slips of this muscle interdigitate with the external oblique
abdominal muscle. It lies close to the thorax and passes underneath the scapula to its
distal attachment.

The lowest five digitations is the strongest portion of the muscle. On well-developed
individuals, the lower digitations may be seen and palpated near their proximal
attachment on the ribs when the arm is overhead.

When the serratus anterior is paralyzed or weak and forward reaching is attempted, a
typical winging of the medial border of the scapula is seen as the scapula fails to
protract or slide forward on the rib cage or to remain in contact with it.

Trapezius

The trapezius is a superficial muscle of the neck and upper back.

Because of its shape, it has been called the shawl muscle. Early anatomists named it
musculus cucullaris (shaped like a monks hood). The present name refers to its
geometric shape. From a widespread origin, the muscle fibers converge to its distal
attachments.

Scapular upward rotation and protraction occur together during glenohumeral flexion. As
the axis for scapular rotation moves from the root of the scapular spine to the acromion
process during upward rotation, the moment arm for the lower trapezius becomes larger
for upward rotation. In full abduction with scapular retraction, all parts of the trapezius
are recruited: retraction of the shoulder girdle by the entire muscle and upward rotation
of the scapula by the upper and lower portions of the muscle. Although the upper and
lower trapezius work together to perform scapular upward rotation, their fiber
arrangement also allows them to perform contradicting motions; the upper trapezius
produces scapular elevation whereas the lower trapezius produces scapular depression.

Dysfunction of the muscle results in an inability to achieve full scapular upward rotation.
In complete trapezius paralysis, elevation is limited to 120 since elevation is the result
motion only at the glenohumeral joint.

Rhomboid Major and Minor

The rhomboids (Gr. rhombos, parallelogram-shaped) that connect the scapula with the
vertebral column lie under the trapezius.

The more cranial portion is known as rhomboid minor; the larger, more caudal portion is
the rhomboid major.

The rhomboids are made up of parallel fibers, the direction of which is almost
perpendicular to those of the lower trapezius.

Weakness or loss of rhomboids function will cause the scapula to assume a protracted
position on the thorax. Posterior observation of such a patient reveals a scapula
positioned farther laterally from the thoracic spinous processes than the normal 6 cm
from the thoracic spinous processes.

Pectoralis Minor

The pectoralis minor (L. pectus, breast bone, chest) is located anteriorly on the upper
chest, entirely covered by the pectoralis major.

The muscle spans from proximal to distal insertions to give the muscle a triangular
shape.

Weakness of this muscle results in reduced strength during scapular depression and
downward rotation of the scapula against resistance.

Levator Scapulae

The levator scapulae, as its name indicates, is an elevator of the scapula, an action it
shares with the upper trapezius and with the rhomboids.

The levator is difficult to palpate since it is covered by the upper trapezius, and its upper
portion is also covered by the sternocleidomastoid muscle.

Note that the line of action of the upper trapezius produces elevation and upward
rotation of the scapula, whereas the levatorat least in a certain rangehas a
downward rotary action on the scapula. Therefore, the levator muscle is more likely a
scapular elevator when elevation occurs with the scapula in a downward rotation
position, as in shrugging the shoulder when the hand is behind the body.

Deficiencies in this muscle produce a reduced ability to elevate and downwardly rotate
the scapula.

2) Glenohumeral Stabilizing Muscles of the Shoulder

-

These muscles include the rotator cuff group. The rotator cuff muscles provide
glenohumeral stability as well as glenohumeral motion. Weakness or dysfunction of any
of these muscles will result in reduction of the motion the specific muscle provides as
well as a significant decrease in glenohumeral joint stability during shoulder activities.
Since they offer some stability to the glenohumeral joint, the biceps and triceps are also
included in this group of glenohumeral stabilizers.

The four rotator cuff muscles are sometimes referred to as the SITS muscles. This
label refers to the order in which they attach to the humerus and their arrangement
around the glenohumeral joint.

Supraspinatus

As its name indicates, the supraspinatus muscle is located above the spine of the
scapula. It is hidden by the trapezius and the deltoid; the trapezius covers its muscular
portion and the deltoid lies over its tendon.

Note that the deepest portion of the supraspinatus lies too deep in the supraspinous
fossa to be palpated, but the more superficial fibers of the supraspinatus may be felt
through the trapezius. In addition to the method of palpation, the muscle may also be
palpated with the subject seated. In this position, first identify the spine of the scapula
and place your palpating fingers on the muscle immediately cranial to the scapular spine
(they should be moved along the scapular spine until the best spot for palpation is
located). A quick active abduction movement in an early, short range of abduction
motion is performed by the subject as the clinician palpates a momentary contraction of
the muscle. In wider ranges of abduction, the supraspinatus is more difficult to palpate
because the trapezius becomes increasingly tense and it is then not easy to distinguish
one muscle from the other.

The supraspinatus is capable of performing the total motion of abduction without the
assistance of the deltoid. This has been demonstrated in persons with paralysis of the
deltoid muscle in both poliomyelitis and axillary nerve block.

Howell and associates found the supraspinatus is able to abduct the humerus against
resistance and to contribute approximately 50% of normal maximum isokinetic torque.

Additionally, however, Howell and associates proposed that the supraspinatus may
contribute to 12% of abduction torque at and above 120 of motion.

Infraspinatus and Teres Minor

Although the infraspinatus and teres minor are supplied by two different nerves, they are
described together here because they are closely related in location and action. The
infraspinatus lies closest to the spine of the scapula and occupies most of the
infraspinatus fossa. The teres minor (L. teretis, round and long) is attached to the lateral
border of the scapula. The tendons of both muscles are adherent to and blend with the
capsule.

The largest parts of the infraspinatus and the teres minor are superficial and may be
palpated; however, some portions are covered by the trapezius and the posterior deltoid.
The distal attachments of these muscles can be palpated on the greater tubercle of the
head of the humerus just distal and anterior to the acromion if the glenohumeral joint is
passively hyperextended and the deltoid muscle is relaxed.

If pathology is present, palpation of these structures may produce complaints of pain or

discomfort.

Subscapularis

The subscapularis is located on the anterior scapula. The muscles tendon passes over
the anterior aspect of the capsule of the glenohumeral joint.

Depending on the arm position, the subscapularis can flex, extend, adduct, or abduct the
glenohumeral joint in addition to its primary medial rotation function. Other subscapularis
functions are dependent upon its moment arm and are, therefore, related to the
glenohumeral position. When the arm is overhead, the subscapularis is able to assist
with extension. There is also evidence that it may work to adduct when the shoulder is
medially rotated and abduct when the shoulder is laterally rotated. The subscapularis
has a cross section nearly equal that of the middle deltoid, which indicates that the
muscle is of considerable size.

Biceps Brachii and Triceps Brachii

The biceps and triceps muscles do not belong to the rotator cuff; however, the two
heads of the biceps and the long head of the triceps cross the shoulder joint and,
therefore, act on it.

The long and short biceps heads attach to the supraglenoid tubercle and to the coracoid
process, respectively, whereas the triceps attaches to the infraglenoid tubercle.

At the shoulder, the biceps serves as a glenohumeral joint flexor and an abductor, and
the triceps is an extensor and an adductor of the glenohumeral joint.

The long head of the biceps is also important in stabilizing the humeral head in the
glenoid during glenohumeral motion. When stimulated, the biceps tendon pushes the
humeral head into the lower portion of the glenoid to reduce stress on the joint.
However, it must be kept in mind that since the long head of the biceps crosses both the
shoulder and elbow joints, its influence on one joint is dependent upon its position at the
other.

Itoi and colleagues demonstrated that both the long and short heads of the biceps added
to shoulder stability when the shoulder was in abduction and lateral rotation. They also
concluded from their investigation that as the joints stability provided by other structures
decreased, such as with a tear in the anterior capsule, the biceps role increased. It is
agreed upon by several investigators that the biceps is an important stabilizing structure
for the glenohumeral joint during elevation, especially if there is injury to other stabilizing
structures.

When the deltoid and the supraspinatus are paralyzed, the long head of the biceps is
capable of substituting as an arm elevator. The biceps is able to provide this motion
when the glenohumeral joint is in lateral rotation, slightly anterior to the frontal plane and
without resistance or a tool in the hand. This motion is useful for placement of the hand
over the head, but the long head of the biceps is not strong enough to lift objects or to
perform work in this position. The long head of the triceps also lends stability to the
glenohumeral joint during elevation activities. As the humerus moves into abduction, the
triceps long head helps to steady the humeral head in the glenoid. During weightbearing activities, the triceps also provides stabilization of the glenohumeral joint; Marisa
Pontillo and associates found that as upper extremity weight-bearing activities became
more difficult, the triceps becomes more active as a shoulder stabilizer.

3) Large Muscle Movers of the Shoulder

-

These muscles have their proximal attachments on the trunk and their distal attachments
on the humerus, having little or no attachment to the scapula. They act on the humerus
as primary movers, but through their connection to the humerus, they may also indirectly

affect the position of the entire shoulder girdle. Because of their attachments, these
muscles each perform multiple actions at the shoulder joint.

Deltoid

The deltoid (Gr. delta, the letter ; eidos, resemblance) is a large, superficial muscle
consisting of three parts: anterior, middle, and posterior.

The muscle covers the glenohumeral joint on all sides except in the inferior axillary
region and comprises 40% of the mass of the scapulohumeral muscles.

The muscle is covered by skin only, so it is easy to observe and palpate in its entirety.
The characteristic roundness of the normal shoulder is due to the deltoid muscle.

The three portions of the deltoid should be observed in action while horizontal abduction
and adduction are performed and in pulling and pushing activities. Although all three
heads of the deltoid work together to produce abduction as a common motion, similar to
the upper and lower trapezius, the anterior and posterior portions of the deltoid also act
antagonistically to each other; the anterior deltoid produces horizontal flexion (horizontal
adduction) whereas the posterior deltoid produces horizontal extension (horizontal
abduction). Similarly, the anterior deltoid contributes to medial rotation whereas the
posterior deltoid laterally rotates the humerus. In normal abduction, the supraspinatus
initiates motion. However, in persons with supraspinatus paralysis or debilitating injury,
the deltoid is able to abduct the humerus throughout the range of motion if the other
functioning rotator cuff muscles are able to counteract the deltoids translatory force.
Even though deltoid only abduction occurs, it is produced with less than normal strength.

Howell and associates found an approximately 50% reduction in maximum isokinetic

abduction torque with nerve blocks to the suprascapular nerve.

Latissimus Dorsi

The name latissimus dorsi is derived from the Latin latus, meaning broad.

This muscle is the broadest muscle of the low back and the lateral thoracic region. It lies
superficially, except for a small segment that is covered by the lower trapezius. The
largest part of this muscle is thin and sheet-like on the posterior thorax, which makes it
difficult to distinguish from the fascia and the deeper muscles of the back.

The latissimus forms the posterior fold of the axilla.

Its shoulder functions commonly relate with those of the teres major and the long head
of the triceps.

Teres Major

The teres major lies distal to the teres minor on the lateral scapula border.

It is round like the minor, but larger.

The muscular portion of the teres major is well accessible to palpation, but the tendon of
its distal attachment is not. The teres major acts in most pulling activities when the
shoulder is extended or adducted against resistance. Its function is closely aligned with
that of the latissimus dorsi.

Pectoralis Major

Its name (L. pectus, breastbone, chest) indicates that the pectoralis major is a large
muscle of the chest.

It has an extensive origin but does not cover nearly as large an area as the latissimus
dorsi.

The muscle is described as consisting of two parts: the clavicular and sternocostal. This
delineation into two segments is based on its muscle fiber directions and functions. Their
fiber arrangements and sites of proximal attachments allow these two heads to work
independently of one another during shoulder flexion and extension. Because of its wide
origin with a convergence of its fibers toward the axilla, the muscle takes the shape of a
fan. The manner in which the muscle fibers approach their distal attachment should be
notedthe tendon appears to be twisted around itself, so that the uppermost fibers
attach lowest on the crest and the lower fibers attach more proximally.

Coracobrachialis

The name of this muscle identifies its proximal and distal insertions.

Parts of this muscle are covered by the deltoid, pectoralis major, and biceps brachii.

It is considered a mover of the glenohumeral joint rather than a stabilizer since its line of
pull is sufficiently distant from the joints axis of motion.
SHOULDER MOTION WITH MUSCLES
1. Shoulder Flexion
-the motion occurs in the saggital plane around the medial lateral
axis(180 degrees)
Muscles:

a. Ant. Deltoid
b. Coracobrachialis
2. Shoulder Extension
-motion occurs in the saggital plane and mediolateral axis (50 degrees)
Muscles:
a. Latissimus Dorsi
b. Posterior Deltoid
c. Teres Major
3. Shoulder Scaption
-arm elevation in the plane of scapula to anterior coronal plane about
halfway between shoulder flexion and abduction
Muscles:
a. Deltoid (Anterior and Middles fibers)
b. Supraspinatus
4. Shoulder Abduction
-occurs in the frontal plane and anteroposterior axis
Muscles:
a. Deltoid (middle fiber)
b. Supraspinatus
5. Shoulder External (Lateral) Rotation
-ocvurs in the transverse plane and around the vertical axis (90 degrees)
Muscles:
a. Infraspinatus
b. Teres Minor
6. Shoulder Internal (Medial) Rotation
-occurs in the transverse plane and around vertical axis
Muscles:
a. Subscapularis
b. Pectoralis Major
c. Latissimus Dorsi
d. Teres Major

IV. ETIOLOGY
Although the etiology remains unclear, adhesive capsulitis can be classified as primary
or secondary. Primary frozen shoulder is considered primary if the onset is idiopathic
while secondary results from a known cause or surgical event.
Summary of Primary and Secondary Adhesive Capsulitis Etiology:
Primary

Adhesive

Capsulitis

Secondary Adhesive Capsulitis

Systemic

Extrinsic

Intrinsic

Thyroid Disease

Cardiac or Breast

Impingement

surgery
Hyperlipidemia

Cerebrovascular

Tendinopathy

Accident
Idiopathic

(of

Hypoadrenalism

Osteoarthrits

Radiculopathy

unknown etiology or
condition)

Cervical

COPD

Dislocation or
shoulder trauma

Osteopenia/reduced
Ischemic heart
conditions
Diabetes Mellitus
Bonemineral density

Post-operative causes:
o Shoulder surgery for conditions such as rotator cuff tear, proximal humerus
fracture, shoulder instability and arthritis may result in stiffness due to aggressive
scar formation during the healing process or prolonged immobilization to protect
a surgical repair. (www.sosmed.org)
Post-traumatic causes:
o Shoulder may result in a frozen shoulder from prolonged immobilization, scar
formation during tissue healing or from a mechanical block to movement as may
occur if bony fractures heal in the wrong way. (www.sosmed.org)
Other risk factors of Adhesive Capsulitis:
o low pain tolerance
o poor compliance with exercise
Other diseases that increase the risk for frozen shoulder:
o Parkinson disease
o Inflammatory arthritis

Autoimmune disease

CONDITIONS LINKED WITH FROZEN SHOULDER

THYROID DISORDER
-

study

reported

that

thyroid

disorders

are

frequently

accompanied

by

musculskeletal disorders such as adhesive capsulitis

- Some common signs of a thyroid condition are muscle and joint aches, weakness
in the arms
BREAST CANCER
- a month after breast surgery, patient may experience stiff shoulder
-naturally, patient will try to protect arm from hurting by keeping it immobilized
DIABETES
-diabetes causes a greater risk of developing frozen shoulder but the exact reason is
unknown
STROKE
-

there is a prolonged contraction of muscle due to painful stimulus

weakness on one side of the body can lead to conditions such as muscle

stiffness, spasticity and shoulder problems

V. PATHOPHYSIOLOGY

LONG HEAD OF BICEPS AND ROTATOR CUFF

UNDERGO REPEATED STRAIN

INFLAMMATION OF JOINT CAPSULE

PAIN, REDNESS, HEAT,
SWELLING OF JOINT CAPSULE

THICKENING OF THE CAPSULE

LOSS OF FUNCTION

PROLONGED
IMMOBILIZATION

PROLIFERATION OF FIBROBLAST (FIBROSIS)

CAPSULAR CONTRACTION

LOSS OF MOVEMENT & INCREASE IN PAIN

ADHESIVE CAPSULITIS

With an injury to any component of the shoulder complex, inflammation occurs in the
joint along with swelling and distention of joint capsule. With prolonged immobilization,
thickening of the capsule may ensue possibly attributable to proliferation of fibroblasts and
capsular contraction. Capsular tightness leads to a loss of movement and an increase in pain,
especially at night.

VI. SIGNS AND SYMPTOMS

STAGE

DURATION (months)

1-3 months

SIGNS AND SYMPTOMS

Painful shoulder movements,
minimal restriction in motion
Painful shoulder movement,

3-9 months

profressive loss of
glenohumeral joint motion
Reduced pain with shoulder

9-15 months

movement, severely restricted

glenohumeral joint motion

Minimal pain, progressive

4

15-24 months

normalization of glenohumeral
joint motion

Common Structural and Functional Impairments

Night pain and disturbed sleep during acute flares
Pain on motion and often at rest during acute flares
Mobility: decreased joint play and ROM, usually limiting external rotation and
abduction with some limitation of internal rotation and elevation in flexion
Posture: possible faulty postural compensations with protracted and anteriorly
tilted scapula, rounded shoulders, and elevated and protected shoulder
Decreased arm swing during gait
Muscle performance: general muscle weakness and poor endurance in the
glenohumeral muscles with overuse of the scapular muscles leading to pain in
the trapezius, levator scapulae, and posterior cervical muscles
Substitution for limited glenohumeral motion with increased scapular motion,
especially elevation.

Common

Activity

Limitations

and

Participation

Restrictions

(Functional

Limitations and Disabilities)

` Inability to reach overhead, behind head, out to the side, and behind back;
thus, having difficulty dressing (putting on a jacket or coat or in the case of
women, fastening undergarments behind their back), reaching hand into back
pocket of pants (to retrieve wallet), reaching out a car window (to use an ATM
machine), self-grooming (combing hair, brushing teeth, washing face), and
bringing eating utensils to the mouth
Difficulty lifting weighted objects, such as dishes into a cupboard
Limited ability to sustain repetitive activities

VI. DIAGNOSTIC TOOLS

Arthrography
An arthrogram of the shoulder is useful for delineating many of the soft tissues and
recesses around the glenohumeral joint. The joint can normally hold approximately 16
mL to 20 mL of solution. With adhesive capsulitis (idiopathic frozen shoulder), the
amount the joint can hold may decrease to 5 mL to 10 mL. The arthrogram shows a
decrease in the capacity of the joint and obliteration of the axillary fold. Also, there is an
almost complete lack of filling of the subscapular bursa with adhesive capsulitis. Tearing
of any structures, such as the supraspinatus tendon and rotator cuff, may result in
extravasation of the radiopaque dye.

Typical arthrographic picture in adhesive capsulitis. Note the absence of a

dependent axillary fold and poor filling of the biceps. (From Neviaser JS: Arthrography of the
shoulder joint: study of the findings of adhesive capsulitis of the shoulder. J Bone Joint Surg

SPECIAL TESTS
Speeds Test
Position: Sitting with shoulder at 90 flexion and slight ER, elbow extension and
forearm supination
Stimulus: Apply downward resistance into shoulder extension
(+) Response: Localized pain over biceps tendon origin

 Drop Arm (Codmanns ) Test

Position: Sitting/Standing
Stimulus: Examiner abducts arm to 90 and pt. drops the arm slowly
(+) Response: inability to return arm slowly or has severe pain

Hawkins Kennedy Impingement Test

Position: Sitting
Stimulus: Passive flexion to 90 and IR of the arm with the elbow flexion; stabilize
elbow and push down the wrist into more IR
(+) Response: Pain in the area of supraspinatus/ coracoacromial ligament
Neer Impingement Test
Position: Sitting
Stimulus : Pt.s arm is forcibly elevated thru forward flexion by examiner causing a
jamming of the greater tuberosity against the anteroinferior border of the acromion.
(+) Response: Pain shows on pt.s face
Apleys Scratch Test

Position: Sitting or standing

Stimulus: Passive adduction; approximating elbow to opposite shoulder
(+) Response: Pain at AC joint
Suprespinatus (Empty Can) test

Position: Sitting
Stimulus: Pt.s shoulder abducted to 90 with neutral rotation, examiner resist.
Shoulder is then IR (thumbs down) and angled forward 30 (empty can position) as
resistance is given again.
(+) Response: weakness and pain

VII DIFFERENTIAL DIAGNOSIS

FROZEN

ROTATOR

ATRAUMATIC

CERVICAL

SOULDER

CUFF LESIONS

INSTABILITY

SPONDYLOSIS

Age 30 to 50
years
Pain and
weakness after
eccentric load

Age 10 to 35
years
Pain and
instability with
activity
No history of
trauma

Age 50+ years

acute and
chronic

OBSERVATION

Age 45+
(insidious type).
Insiduous onset
or after trauma
or surgery.
Functional
restriction of
lateral rotation,
abduction, and
medial rotation
Normal bone and
soft tissue
outlines

Normal bone and

soft tissue
outlines

Minimal or no
cervical spine
movement
Torticollis may
be present

ACTIVE

Restricted ROM
Shoulder hiking

Normal bone and

soft tissue
outlines
Protective
shoulder hike
may be seen
Weakness of
abduction or
rotation, or both
Crepitus may be
present
Pain if
impingement
occurs

Full or excessive
ROM

Limited ROM
with pain

Normal or
excessive ROM

Limited ROM
(symptoms may
be exacerbated)

Pain and
weakness on
abduction and
lateral rotation

Normal

None

Drop arm
positive
Empty can test
positive

Load and shift

test positive
Apprehension
test positive
Relocation test
positive
Augmentation
tests positive

Not affected

Not affected

Normal, except if
nerve root
compressed
Myotome may be
affected
Spurlings test
psositive
Distraction test
positive
ULNT positive
Shoulder
abduction test
positive
Dermatomes
affected
Reflexes affected

HISTORY

MOVEMENT

PASSIVE
MOVEMENT

RESISTED
ISOMETRIC

Limited ROM,
especially in
lateral rotation,
abduction, and
medial rotation
(capsular
pattern)
Normal, when
arm by side

MOVEMENT

SPECIAL
TESTS

SENSORY
FUNCTION AND

REFLEXES
PALPATION

DIAGNOSTIC
IMAGING

Not painful
unless capsule is
stretched
Radiography:
Negative
Arthrography:
Decreased
capsular size

CONDITION
Adhesive Capsulitis

Posterior Glenohumeral
Dislocation

Subacromial rotator cuff

impingement

Proximal Biceps Tendinitis

Superior labral tears

Tender over
rotator cuff

Anterior or
posterior pain

Radiography:
Upward
displacement of
humeral head;
acromial spurring
MRI diagnostic

Negative

DIFFERENTIATING
SIGNS/SYMPTOMS
- Insiduous onset or after trauma or
surgery.
-painful restriction in shoulder range
of motion
-posterior shoulder dislocations
usually occur after a traumatic event
and are also traditionally attributed
to electrocution or seizure.
- Acute onset of pain and immediate
severe loss of motion help
differentiate from adhesive
capsulitis.
- Typically causes pain with
shoulder elevation between 60 and
120 due to the rotator cuff tendons
compressing against the anterior
acromion and coracoacromial
ligament (painful arc syndrome).
- There may be weakness due to
pain.
- Tenderness at bicipital groove
- Pain in the anterior region of the
shoulder with Speed test (resisted
forward arm flexion with the elbow
extended) or Yergason test
(resisted forward supination).
-Pain and decreased range of
motion is common.
-Weakness is not a presenting
symptom.
-Pain elicited with active
compression test (resisted arm
elevation with the arm 15
adducted, forward flexed parallel
with the floor and maximal
pronation).

Tender over
appropriate
vertebra or facet
Radiography:
Narrowing
Osteophytes

DIFFERENTIATING
INVESTIGATIONS
Radiography: Negative
Arthrography:
Decreased capsular size
Axillary view plain
radiograph will show a
posterior shoulder
dislocation.

Shoulder MRI may show

evidence of
inflammation in the
subacromial space.

MRI may reveal a

subluxated long head of
the biceps tendon, or
demonstrate
degeneration within the
proximal biceps tendon.
MRI or MR arthrograms
demonstrate superior
glenoid labral tears.

Acromioclavicular joint
arthrosis

-Anterior shoulder pain.

-Usually have pain with cross arm
adduction, and no limitation of
passive range of motion.

Glenohumeral Arthritis

-Glenohumeral arthritis often

presents with restricted range of
motion and pain. Patients may note
a sensation of popping or crepitus

Either plain film

radiographs or MRI will
demonstrate
degeneration of the
acromioclavicular joint,
distal clavicle osteolysis,
and cystic formation at
the end of the clavicle.
-Plain radiographs of the
shoulder will
demonstrate decreased
joint space and marginal
osteophytes. Often an
AP radiograph of the
shoulder will
demonstrate an
osteophyte at the
inferior articular margin
of the humeral head that
is diagnostic of
osteoarthritis.

IX MANAGEMENT
A. PHARMACOLOGICAL MANAGEMENT
FIRST LINE
NSAIDs are one of the most common intervention in treating frozen shoulder. It is
most beneficial in stage1 when pain is the predominant feature, if contraindicatd,
reasonable alternatives include acetaminophen or opioid analgesics
Oral corticosteroid: Rarely used in clinical practice, but evidence demonstrates shortterm improvement in pain and ROM (up to 6 weeks). Like NSAIDs, oral steroids do not
alter long-term outcomes, are not without side effects and are most likely beneficial early
in course of the disease (stage 1 and stage 2)
Subacromial (SA) corticosteroid injection: Some evidence regarding shorttermimprovement in pain and ROM when using SA injection in conjunction with physical
therapy.
Intra-articular

(IA)

corticosteroid

injections:

Has

demonstrated

short-term

improvement in pain and ROM similar to that of oral corticosteroids. Improvements may

persist up to 4 months if used in conjunction with physical therapy, but may require serial
injection.
Capsular distension injections : This method of treatment has been described for
patients under local anesthesia. The joint is injected to its limits with local anesthetic to
attempt to stretch the capsule. This technique is often poorly tolerated because of pain
that is experienced during the process as the entire shoulder is not anesthetized from
the intra-articular injection.
SECOND LINE
Tricyclic antidepressants (amitriptyline) have been used as neuromodulators. No
evidence evidence exists support use in adhesive capsulitis.

B. MEDICAL SURGICAL MANAGEMENT

Arthroscopic Capsular Release
In some cases, a closed manipulation procedure may fail to restore motion to the shoulder.
These patients may be candidates for selective arthroscopic capsular release, which has proven
to be a safe, effective way to eliminate scar tissue from the capsule. During an arthroscopy, a
small fiberoptic instrument is inserted into the joint. The scar tissue surrounding the joint is
removed and a gentle manipulation follows. This will significantly reduce the risk of fracture or
injury if the frozen shoulder has been present for some time. If necessary, other disorders within
the shoulder can be addressed at the same time.
Shoulder Arthroscopy
Procedure
Your surgeon will first inject fluid into the shoulder to inflate the joint. This makes it easier to see
all the structures of your shoulder through the arthroscope. Then your surgeon will make a small
puncture in your shoulder (about the size of a buttonhole) for the arthroscope. Fluid flows
through the arthroscope to keep the view clear and control any bleeding. Images from the
arthroscope are projected on the video screen showing your surgeon the inside of your shoulder
and any damage.

Once the problem is clearly identified, your surgeon will insert other small instruments through
separate incisions to repair it. Specialized instruments are used for tasks like shaving, cutting,
grasping, suture passing, and knot tying. In many cases, special devices are used to anchor
stitches into bone.
Manipulation under anesthesia
Manipulation under anesthesia as a means of treatment has been advocated. This method
allows return of ROM in the operating room. Immediate postoperative physical therapy can be
initiated with this form of treatment. Manipulation under anesthesia has the disadvantage in that
tissues that are stretched while the patient is under anesthesia may cause pain when awake.
This can potentially slow recovery. When surgical release is added to this procedure it induces
further surgical trauma to the shoulder and may slow rehabilitation
C. PT MANAGEMENT
PHYSICAL MODALITIES
REHABILITATION APPROACH BASED PON THE STAGES OF ADHESIVE CAPSULITIS (Wyss et. al.)
STAGE

GOALS

MODALITIES

Disrupt inflammatory- pain cycle;

I

control pain; educate in support of the

To control pain and inflammation: moist

upper limb, activity modification; retard

heat, cryotherapy and TENS

progression from synovitis to fibroplasia

Control inflammation/ pai, minimize
II

ROM loss, re-establish force couples to

maximize S-H rhythm
Increase ROM/ flexibility, restore

III

function, avoid painful arcs of active

motion, AROM=PROM

MANUAL TECHNIQUE AND THERAPEUTIC EXERCISES

To decrease pain and inflammation,

and to promote relaxation and increase
tissue extensibility: hydrotherapy, HMP
and TENS
To increase tissue extensibility:
hydrotherapy, HMP

Management guidelines are progressed based on the continuum of stages and are the same as
for acute (maximum protection during stages 1 and 2), subacute (controlled motion during stage
3), and chronic (return to function during stage 4) joint pathology.
Glenohumeral Joint Hypomobility: ManagementProtection Phase
Control Pain, Edema, and Muscle Guarding
The joint may be immobilized in a sling to provide rest and minimize pain.
Intermittent periods of passive or assisted motion within the pain free/protected
ROM and gentle joint oscillation techniques are initiated as soon as the patient
tolerates movement in order to minimize adhesion formation.
Gentle soft tissue mobilization to the cervical and periscapular muscles may
improve patient comfort and minimize guarding, as may cervical range of motion
and/or cervical grade I or II passive intervertebral mobilizations/manipulations.

Maintain Soft Tissue and Joint Integrity and Mobility

PRECAUTION: If there is increased pain or irritability in the joint after use of the
following techniques, either the dosage was too strong or the techniques should
be modified by decreasing the range of passive movement or delaying joint
glides.

CONTRAINDICATION: If there are mechanical restrictions causing limited

motion, appropriate tissue stretching should initiated only after the inflammation
subsides.
Passive range of motion (PROM) in all ranges of pain-free motion. As pain
decreases, the patient is progressed to active ROM with or without assistance,
using activities such as rolling a small ball or sliding a rag on a smooth table top
in flexion, abduction, and circular motions. Be sure the patient is taught proper
mechanics and avoids faulty patterns, such as scapular elevation or a slumped
posture.
Passive joint distraction and glides, grade I and II with the joint placed in a
pain-free position.
Pendulum (Codmans) exercises are techniques that use the effects of gravity
to distract the humerus from the glenoid fossa. They help relieve pain through

gentle traction and oscillating movements (grade II) and provide early motion of
joint structures and synovial fluid. No weight is used during this phase of
treatment.
Gentle muscle setting to all muscle groups of the shoulder and adjacent
regions, including cervical and elbow muscles because of their close association
with the shoulder girdle.

Instructions are given to the patient to gently contract a group of muscles while
slight manual resistance is appliedjust enough to stimulate a muscle
contraction without provoking pain.

The emphasis is on rhythmic contracting and relaxing of the muscles to help

stimulate blood flow and prevent circulatory stasis.

Maintain Integrity and Function of Associated Regions

Complex regional pain syndrome type I (reflex sympathetic dystrophy) is a
potential complication after shoulder injury or immobility. Therefore, additional
exercises, such as having the patient repetitively squeeze a ball or other soft
object, may be given for the hand.
The patient is educated on the importance of keeping the joints distal to the
shoulder complex as active and mobile as possible. The patient or family
member is taught to perform ROM exercises of the elbow, forearm, wrist, and
fingers several times each day while the shoulder is immobilized. If tolerated,
active or gentle resistive ROM is preferred to passive ROM for a greater effect on
circulation and muscle integrity.
If edema is noted in the hand, instruct the patient to elevate the hand above the
level of the heart whenever possible.
Cervical ROM (active and/or passive), intervertebral joint mobilizations, and
soft tissue mobilization should also be considered.
GH Joint Hypomobility: ManagementControlled Motion Phase
Control Pain, Edema, and Joint Effusion
Functional activities. It is important to carefully monitor activities. If the joint is
immobilized, the amount of time the shoulder is free to move each day is
progressively increased.

 Range of motion. ROM for glenohumeral and scapula motions is progressed

up to the point of pain. The patient is instructed in the use of self-assistive ROM
techniques, such as the wand exercises or hand slides on a table.
PRECAUTION: With increased pain or decreased motion after these techniques,
the activity may be too intense or the patient may be using faulty mechanics.
Reassess the technique and modify it by restricting the joint to a safer range of
motion, correcting faulty movements, or altering the intensity, frequency, and/or
duration of the technique.

Progressively Increase Joint and Soft Tissue Mobility

Passive joint mobilization techniques. Grade III sustained or grade III and IV
oscillations that focus on the restricted capsular tissue at the end of the available
ROM are used to increase joint capsule mobility. End-of-range techniques
include rotating the humerus and then applying either a grade III distraction or a
grade III glide to stretch the restrictive capsular tissue or adhesions.
Use a grade I distraction with all gliding techniques. If the joint is highly irritable
and gliding in the direction of restriction is not tolerated, glide in the opposite
direction. As pain and irritability decrease, begin to glide in the direction of
restriction.
PRECAUTION: Carefully monitor the joint reaction to the mobilization stretches; if
irritability increases, grade III or IV techniques should not be undertaken until the chronic
stage of healing.

Self-mobilization techniques. The following self-mobilization

techniques may be used for a home program.
CAUDAL GLIDE. Patient position and procedure:
Sitting on a firm surface and grasping the fingers
under the edge. The patient then leans the trunk away
from the stabilized arm.
ANTERIOR GLIDE. Patient position and procedure:
Sitting with both arms behind the body or lying supine

supported on a solid surface. The patient then leans the body weight between
the arms.
POSTERIOR GLIDE. Patient position and procedure: Prone, propped up on
both elbows. The body weight shifts downward between the arms.
Manual stretching. Manual stretching techniques are used to increase mobility in
shortened muscles and related connective tissue.
Self-stretching exercises. As the joint reaction becomes predictable and the patient
begins to tolerate stretching, self-stretching techniques are taught.
Inhibit Muscle Spasm and Correct Faulty Mechanics
Muscle spasm may lead to a faulty deltoid-rotator cuff mechanism and
scapulohumeral rhythm when the patient attempts arm elevation. The head of the
humerus may be positioned cranially in the joint, making it difficult and/or painful
to elevate the arm because the greater tuberosity impinges on the
coracoacromial arch. In this case, repositioning the head of the humerus with a
caudal glide is necessary before proceeding with any other form of shoulder
exercise.
The patient also needs to learn to avoid hiking the shoulder when at rest or
when elevating the arm. The following techniques may address these problems
and faulty mechanics.
Gentle joint oscillation techniques to help decrease the muscle spasm (grade I
or II).
Sustained caudal glide joint techniques to reposition the humeral head in the
glenoid fossa.

Protected weight bearing, such as leaning hands against a wall or on a table,

stimulates co-contraction of the rotator cuff and scapular stabilizing muscles and
improves synovial fluid movement through hyaline cartilage compression.
Techniques are progressed by gentle rocking forward/backward and side-to-side,
moving from bilateral to unilateral, increasing the angle of the joint, or adding
perturbations.
GH internal/external rotation strengthening to facilitate stabilization of the
humeral head .

 Movement retraining to minimize the substitution pattern of scapular elevation

can be initiated by providing the visual feedback of a mirror or the tactile
feedback of the opposite hand placed on the ipsilateral upper trapezius.

Improve Joint Tracking

Mobilization with movement (MWM) techniques may assist with retraining muscle
function for proper tracking of the humeral head.
Shoulder MWM for painful restriction of shoulder external rotation.
Patient position: Supine lying with folded towel under the scapula; the elbow is
near the side and flexed to 90. A cane is held in both hands.

Therapist position and procedure: Stand on the opposite side of the bed facing
the patient and reach across the patients torso to cup the anteromedial aspect of
the head of the humerus with reinforced hands. Apply a pain-free graded
posterolateral glide of the humeral head on the glenoid. Instruct the patient to use
the cane to push the affected arm into the previously restricted range of external
rotation. Sustain the movement for 10 seconds and repeat in sets of 5 to 10. It is
important to maintain the elbow near the side of the trunk and ensure that no
pain is experienced during the procedure. Adjust the grade and direction of the
glide as needed to achieve pain-free function.
Shoulder MWM for painful restriction of internal rotation and inability to reach
the hand behind the back.
Patient position: Standing with a towel draped over the unaffected upper
trapezius and affected hand at current range of maximum pain-free position
behind back. The patients hand on the affected side grasps the towel behind the
back.

 Therapist position and procedure: Stand facing the patients affected side.
Place the hand closest to the patients back high up in the axilla with the palm
facing outward to stabilize the scapula with an upward and inward pressure. With
the hand closest to the patients abdomen, hook the thumb in the cubital fossa
and grasp the lower humerus to provide an inferior glide. Your abdomen is in
contact with the patients elbow to provide an adduction force to the arm. Have
the patient pull on the towel with the unaffected hand to draw the affected hand
up the back while the mobilization force is being applied in an inferior direction.
Ensure that no pain is experienced during the procedure. Adjust the grade and
direction of glide as needed to achieve pain-free function. Maximal glide should
be applied to achieve end-range loading.

Improve Muscle Performance

Faulty postures or shoulder girdle mechanics, such as scapula elevation or
protraction or excessive trunk movement, displayed when moving the upper
extremity in various functional patterns should first be identified and corrected.
Manual techniques, stretches, and strengthening exercises are initiated to correct
muscle length or strength imbalances, followed by an emphasis on developing
active control of weak musculature. As the patient learns to activate the weak
muscles, progress to strengthening in functional patterns.
Because faulty postures or shoulder girdle mechanics may be impacted by
impaired trunk strength or control, an emphasis on trunk stability should also be
considered
After proper mechanics are restored, the patient should perform active ROM of
all shoulder motions daily and return to functional activities to the extent
tolerated.

GH Joint Hypomobility: ManagementReturn to Function Phase

Progressively Increase Flexibility and Strength
Stretching and strengthening exercises are progressed as the joint tissue
tolerates. The patient should be actively involved in self-stretching and
strengthening by this time, so emphasis during treatment is on maintaining
correct mechanics, safe progressions, and exercise strategies for return to
function. Progressions may include increasing resistance and repetitions,
performing exercises through multiple planes, adding perturbations, and
incorporating regional muscle groups (such as the trunk) into dynamic exercises.
If capsular tissue is still restricting ROM, vigorous manual stretching and joint
mobilization techniques are applied.

References:
Books:
Braddoms Physical Medicine and Rehabilitation by Davis X. Cifu 2nd edition
Therapeutic Exercise Foundations and Techniques by Kisner & Colby 6th edition
Pathophysiology By Lee-Ellen C. Copstead-Kirkhorn, Jacquelyn L.
Essentials of Orthopaedics for Physiotherapist By Ebnezar
The 5-Minute Clinical Consult 2014 By Frank J. Domino, Robert A. Baldor,
Jeremy
DeLisas Physical Medicine & Rehabilitation by Walter R. Fontera 5th edition
Brunnstrums Clinical Kinesiology by Peggy A. Houglum, Dolores B. Bertoti
Therapeutic Programs for Musculoskeletal Disorders By James Wyss, Amrish
Patel
Duttons Orthopaedic Examination, Evaluation, And Intervention Third Edition by:
Mark Dutton, PT
Merriam Medical Dictionary
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