Adhesive Capsulitis (Frozen Shoulder): Outpatient physical therapy using joint

mobilizations.
Lexie Ash

Introduction
Adhesive capsulitis (AC), or frozen shoulder is a shoulder condition characterized by gradual
and painful loss of both active and passive range of motion in all planes of the glenohumeral
joint. Shoulder pain and stiffness are accompanied by severe disability. Often, this results in
absenteeism from work, inability to perform leisure activities, and utilization of health care
resources. (1)
In 1944 American Shoulder and Elbow Surgeons defined it as a condition characterized by
functional restriction of both active and passive shoulder motion for which radiographs of the
glenohumeral joint are essentially unremarkable except for the possible presence of osteopenia or
calcific tendonitis (3)
Adhesive capsulitis is a condition of uncertain etiology. Frozen shoulder affects approximately
2% to 5% of the general population and 10% to 15% of the population with diabetes.
Adhesive capsulitis is a condition of extreme stiffness or immobility in the shoulder joint. Signs
and symptoms usually begin gradually and worsen over time. A frozen shoulder is more likely to
occur if you are recovering from a medical condition or procedure that prevents you from
moving your shoulder. (2) With adhesive capsulitis there will also be a decrease in strength of the
shoulder. Physical therapy will be beneficial to individuals with frozen shoulder to help regain
some lost motion and to improve strength and decrease pain. During the frozen and thawing
stages of adhesive capsulitis it is important to start a home program on ROM and strengthening
right away.

Case description
The patient was a 56 y.o Caucasian male who was involved in a motorcycle accident on August
9th 2015. As a result he sustained a L thumb Bennetts fracture. He saw the surgeon who
performed an ORIF with pinning on August 14th 2015. The patient was immobilized at the
shoulder, elbow and hand. The pt then complained of L shoulder pain and severe stiffness. The
patient reported he was independent with all ADLs, IADLs and driving. Patient was not working
at time of evaluation. For the patients occupation he is a diesel mechanic, which requires lifting
(35 lbs), handling tools, gripping, and overhead work. His past medical history included high
blood pressure.

Examination
The following exam was performed by the physical therapist nine and a half weeks following the
surgery.
Pain in L shoulder and thumb

0/10 at best and 6/10 at worst.

Self care
Home management
Transportation
Occupational
Recreational
Motion
Shoulder
Flexion
Extension
Abduction
Internal rotation
External rotation
Total AROM (TAM)
Wrist
Flexion
Extension
Ulnar deviation
Radial deviation
TAM
Thumb
MCP flexion/extension
IP flexion/ extension
Flexion to base of SF
CMC palmar ABD
CMC radial ABD
Thumb TAM

Moderate limitation
Mild limitation
No limitation
Severe limitation
Severe limitation
Right

Left

155
58
148
63
82
506

96
28
50
23
0
197 (39%)

60
55
30
20
165

35
44
18
10
107 (65%)

-5/36
+30/80
0
50
50
211

-5/23
+25/26
5cm
34
35
118 (56%)

Average of 3 trials
11.3 lbs
100.0 lbs

Difference between L and R

-86%

Dash score of 45%

Muscle strength:
Max grip
Left
Right

After the initial evaluation and exam the following goals were established:
1. Pt will decrease pain to 0-3/10 utilizing the pain scale, to allow independence with ADLs/
IADLs unrestricted by pain in 8 weeks.
2. Pt will increase L shoulder and L hand AROM to WFL of 80-90% total active motion,
based on testing utilizing goniometric measurements, to allow free unrestricted mobility
for ADLs, IADLs and occupational duties within 8 weeks.
3. Pt will increase grip and pinch strength based on testing with handheld dynamometer, to
WFL of less than 25% deficit compared to non involved hand to allow normal gripping
and pinching for ADLs, IADLs and occupational duties in 8 weeks.

4. Pt will increase L shoulder strength, based on a handheld dynamometer, to WFL of less

than 25% deficit compared to uninvolved UE to allow normal reaching, lifting, pushing,
and pulling for ADLs, IADLs and occupational duties within 8 weeks.
5. Pt will present with a 50% or greater decrease in disabilities of the arm, shoulder, and
hand (DASH) to a score of 22.5% within 8 weeks.

Treatment plan
2 times a week for 4 weeks will consist of: Therapeutic exercises: functional A/AAROM of
shoulder wrist and hand, and functional strengthening. Therapeutic activities: dexterity and
handling activities, ADL and IADL training. Neuromuscular re-education: facilitation/
recruitment techniques, PNF, strain counter strain technique, manual techniques: MEM, PROM,
scar mobilization on hand, joint mobilization (when appropriate).

Initial treatment
Manual therapy: PROM shoulder scaption, ER/IR; GH joint mobilization grade 3 anteriorinferior glides, posterior glides. Therapeutic exercise: AROM of thumb MP, IP, radial abd and
palmar abd.
Patient was educated in home exercises that were to be done 3 times a day, which included
pulleys to be done twice a day to work on increasing his shoulder ROM.

Outcomes
Throughout treatment patient gradually improved his ROM of the left shoulder and hand. He was
able to increase his TAM scores to 78% total motion for the shoulder. Patient appeared to be very
compliant with his HEP. He was able to advance his activities to using cones (to promote
shoulder motion). The patient did not return after 6 weeks and we were unable to administer a
strength test. Patients subjective report of ADLs and IADLs did improve. If the patient was
compliant with physical therapy appointments he would be advancing to strengthening exercises
as well as a rotator cuff and scapular stabilization program. The patients muscle guarding was
decreased with PROM in a scapular plane.

Discussion
There was a study done to find the effectiveness of intense mobilization combined with capsular
distension and the results suggest that the most effective treatment for subacute AC is a

combination of intensive mobilization and steroid injection with capsular distension, and helped
to control inflammation, extend joint space, and recover ROM. Therefore, intensive mobilization
should be conducted by a skilled physical therapist.
Several studies have demonstrated the effectiveness of joint mobilization for patients with AC.
The accumulated evidence indicates that not only passive joint mobilization, but also active
mobilization, such as Kaltenborns convex-concave rule and MWM may need to be considered
to improve pain, ROM, and shoulder function. In this study, the IMSID and IM groups received
intensive mobilization and showed improvement in all outcome measures.
There is still debate about the most effective treatment. In general, intra-articular steroid
injections, capsular distension, and joint mobilization therapy are known to be effective in the
treatment of AC. While, joint mobilization techniques improve the mobility of the joint and soft
tissues, researchers have reported different results with regards to pain management. (1)

References:
1. Park, Sun Wook, Han Suk Lee, and Jun Ho Kim. "The Effectiveness of Intensive Mobilization
Techniques Combined with Capsular Distension for Adhesive Capsulitis of the Shoulder." Journal of
Physical Therapy Science. The Society of Physical Therapy Science, n.d. Web.
2. "Abstract." Glenohumeral Posterior Mobilization versus Conventional Physiotherapy for Primary
Adhesive Capsulitis: A Randomized Clinical Trial. N.p., n.d. Web. 21 Nov. 2015.
3. Paul, Antony, Joshua Samuel Rajkumar, Smita Peter, and Litson Lambert. "Effectiveness of Sustained
Stretching of the Inferior Capsule in the Management of a Frozen Shoulder." Clinical Orthopaedics and
Related Research. Springer US, n.d. Web.
4. Maund E, Craig D, Suekarran S, Neilson A, Wright K, Brealey S, et al.Management of frozen shoulder:
a systematic review and cost-effectiveness analysis. Health Technol Assess 2012;16(11)