Learning Outcomes

Anatomy of the shoulder

Definition
Aetiology Pathophysiology

Clinical Phases
Physical presentation Treatment and medication

Follow-up

Anatomy of the shoulder

Anatomy cont
Posterior view: Anterior view:
Teres major

Subscapularis

www.instantanatomy.net

Definition
In 1934, Codman stated, "This entity [FS] is difficult to

define, difficult to treat, and difficult to explain from the point of view of pathology.
Two principal features:

gradual onset of pain and reduced range of motion (active and passive) of the GHJ in a capsular pattern
Uncertain aetiology
Dias et al (2005)

Epidemiology
No regional variations Prevalence is reported to be 2-5%, with an 11%

prevalence in individuals with diabetes. For patients with T1DM, the risk is approximately 40%.
FS affects women more frequently than men and the

mean age of onset is over 40

Brue et al (2007)

Aetiology
Idiopathic disorder.
risk factors: trauma, diabetes, hyperthyroidism, and

dyslipidemia, CVA with upper-extremity paresis, brachial plexus injury, cervical spinal cord injury, and Parkinson disease. repetitive movements of the upper extremities active GHJ synovitis in relation to a systemic inflammatory rheumatologic disorder. surgery to the shoulder, with post-op immobilization
Dias et al (2005)

Pathophysiology
GHJ synovial capsule is often involved
hyperplastic fibroplasia and excessive type III collagen

secretion that lead to soft-tissue contractures (of the coracohumeral ligament, soft tissues of rotator interval, the subscapularis muscle, the subacromial bursae). late phase dx
Why the pain precedes the contracture and why it

resolves before the contracture remains unclear.

Pathophysiology cont
Neurological mechanisms: peripheral alpha-

adrenoreceptor hyperresponsiveness, dorsal-root reflexes (DRRs), central nervous system (CNS) factors, myxoid globular degeneration, and sympathetic autonomic hyperactivity.

Three Clinical Phases

Phase 1 - freezing stage: insidious onset of

predominantly nocturnal pain (without inflammatory, exudative cellular joint processes). End of ROM can increase pain. Lasts 2-9 months.
Phase 2 - frozen stage: pain gradually subsides and

progressive limitation in ROM occurs in a capsular pattern . ADLs can be severely affected. Last 3-12 months.
Phase 3 thawing stage - pain progressively decreases,

and limitations in ROM spontaneously recover over 12-24 months.

Physical presentation
Initial night pain associated with movements of the

shoulder e.g., combing one's hair, reaching overhead for a seat belt (both use AB + ext rot), reaching for one's back pocket (ext and int rot).
Pain can be as high as 10/10 (VAS) In ~90% of patients, the pain lasts for 1-2 years before

subsiding.
Patients with a painful FS have pain during resisted

contraction of all of the rotator cuff tendons

Physical presentation cont

progressive limitation of PROM,

characterized by a painful capsular end-feel (external rotation, followed by abduction, medial rotation and flexion).
Patients typically lift the entire

shoulder girdle when trying to lift the arm.

Treatment
Patient education
dx process, including recovery time

importance of a HEP to increase ROM and function

Occupation

Deterrence (early mobilization and individuals who do

repetitive activities should pay special attention to their posture and the ergonomics of their workstation)

Treatment
Jewell et al, (2009): a randomized clinical trial investigated

the effectiveness of joint mobilization and exercise for patients with FS

The treatments that increased the likelihood of pain

reduction and improved function were: - Joint mobilization performed by a PT and exercise
The treatments that decreased the likelihood of pain

reduction and improved function were: - Ultrasound, Massage, Iontophoresis, Phonophoresis

Treatment
Vermeulen et al (2000) showed that passive

mobilization at the end of range was more effective for improving ROM and function than in the pain-free zone. However, the overall difference between the interventions was small.
In addition, patients appeared to achieve greatest

improvement in ROM when treatment was administered early (Liaw et al, 2000).

Maitlands mobilisations
Accessory: a movement that cannot be performed

independently by the patient but is critical to normal movement e.g. glide, slide, spin, translate
Physiological: movements that a person can carry out

actively e.g. flexion/extension, abduction/adduction, medial/lateral rotation, circumduction

Grading oscillatory joint mobilisation treatment techniques

Grade IV Grade III
frozen & thawing stage

Grade II Grade 1 Beginning of range R1 Maitland

freezing stage

End of expected range

Examples: mobilisations at GHJ

AP glide in abduction AP glide when shoulder is in flexion

Lateral glide in abduction

Distraction to GHJ in abduction passive physiological to increase range of lateral

rotation and flexion Use hold and relax technique to increase flexion

Maitlands Mobilisations
Desired effects: Recover full range painless movement Stretching a stiff joint to restore range Stretching to lengthen contracted, fibrosed or

shortened muscle tissue Relieve pain

Successful treatment

* Increased

ROM and decreased pain at end of range

Other treatment
physical therapy associated with an intra-articular

injection of corticosteroid improves function and ROM more rapidly (p < 0.005) than does intraarticular corticosteroid injection alone (Carette et al, 2003)
Medication for pain relief OT give advice for performing ADLs (eg, dressing,

bathing, grooming).

Other treatment cont

Buchbinder et al (2004)conducted a randomised

double-blind placebo controlled trial supporting the use of hydrodilatation for FS. Significant improvements in function, pain, and ROM at 3 weeks were found, and this benefit was maintained at 6 weeks.

Other treatment cont

Jones et al (1999) conducted a randomized controlled

trial compare the effectiveness of a single suprascapular nerve block with that of series of intraarticular corticosteroid injections. Pain decreased and ROM increased more rapidly with the nerve block.

Follow-up
Bilateral FS may find that even basic ADLs are a

challenge. (eg, toileting, hygiene, dressing, driving, fastening a seat belt).

Further outpatient care (based on the patient's current

status and functional goals)

Conclusion
FS is of insidious onset, with progressive pain and

decreased ROM in a capsular pattern

Physical therapy treatment involves joint

mobilisations and exercise and has been shown to increase the likelihood of pain reduction and improved function in patients with FS

References
Jewell, et al (2009). Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Therapy, 89(5):419-29. Carette et al (2003). Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum., 48(3):829-38 Vermeulen et al (2000). End-range mobilization techniques in adhesive capsulitis of the shoulder joint: A multiple-subject case report. Phys Ther., 80(12):1204-13.

Liaw SC (2000). The effect and timing of physiotherapy on change in range of motion and function in frozen shoulder. Physiother Singapore, 3(3):82-6.
Roy et al (2007). Adhesive Capsulitis , Available at http://emedicine.medscape.com/article/326828-overview

References
Jones et al (1999). Suprascapular nerve block for the treatment of frozen shoulder in primary care: a randomized trial. Br J Gen Pract., 49(438):39-41.
Buchbinder et al (2004). Arthrographic joint distension with saline and steroid improves function and reduces pain in patients with painful stiff shoulder:

results of a randomised, double blind, placebo controlled trial. Annals of the Rheumatic Diseases; 63:302-309
Dias et al (2005). Frozen shoulder. BMJ, 331:1453-1456

Brue et al (2007). Idiopathic adhesive capsulitis of the shoulder: a review. Journal of Knee Surgery, Sports Traumatology, Arthroscopy, vol 15(8), 14337347,
Hengeveld et al (2005). Maitlands peripheral manipulation (4th ed.). Elsevier/Butterworth Heinemann, Michigan

Any Questions?