Adhesive Capsulitis (Frozen Shoulder): Causes, Symptoms & Treatment Options
Adhesive Capsulitis and Frozen Shoulder are terms which are used interchangeably to describe a condition in which the shoulder joint becomes painful, stiff and difficult to move. It is currently considered that Adhesive Capsulitis (Frozen Shoulder) has an unknown cause but clinical presentation demonstrates an individual who has significant reduction in both passive and active shoulder joint range of motion with no obvious cause. Imaging of the shoulder joint typically reveals limited clinical information. While many shoulder conditions may effect active range of motion, the apparent loss of passive range of motion is considered a hallmark clinical feature of Adhesive Capsulitis (Frozen Shoulder). Individuals suffering from Adhesive Capsulitis (Frozen Shoulder) may in fact demonstrate no clinical findings to explain their discomfort. Symptoms of this condition are generally divided into three distinct phases; freezing (painful stage), frozen (stiffening stage) and thawing.
ADHESIVE CAPULSITIS (FROZEN SHOULDER) PHASES
- Freezing (Painful): The initial freezing (painful) phase of Adhesive Capsulitis is marked by a gradual onset of generalized shoulder pain and discomfort that may persisting for weeks to many months.
- Frozen (Stiffening): The second frozen (stiffening) phase is characterized by a progressive reduction in shoulder joint range of motion and movement that may persist for many months to over a year. Majority of individuals note a loss in all shoulder joint movements during this phase.
- Thawing: The final thawing phase is marked by a slow but gradual improvement in movement and reduction of shoulder pain.
ADHESIVE CAPSULITIS EPIDEMIOLOGY
As discussed the exact mechanism of Frozen shoulder remains unclear. However, the condition can be classified as either primary or secondary. Frozen shoulder is considered primary if the onset is idiopathic (unknown) while secondary is classified when there is an apparent cause or surgical intervention. Frozen shoulder syndrome typically affects individuals aged between forty to sixty years of age, with a higher incidence in females. It is estimated that between 2% to 5% of individuals will suffer from this condition during their lifetime. Rarely does Adhesive Capsulitis affect both shoulders at once. Interestingly, Diabetes Mellitus has been identified as a major risk factor for developing Frozen shoulder with Diabetics being up to five times more likely to develop symptoms.
ADHESIVE CAPSULITIS DIFFERENTIAL DIAGNOSES
As with all clinical presentations it is essential to rule out other potential diagnoses which may influence clinical treatment and therefore patient outcomes. Please see a brief list of potential differential diagnoses that your treating practitioner should consider and rule out:
- Shoulder Joint Osteoarthritis: Both abnormalities may present with limitation of shoulder joint range of motion. Shoulder joint radiography should be used to rule out osteoarthritis.
- Shoulder Impingement Syndrome: Commonly affecting the Supraspinatus tendon of the shoulder the hallmark feature will be pain and discomfort upon abduction of the arm. Other ranges of motion are typically unaffected.
- Shoulder Bursitis: The pain and stiffness associated with Adhesive Capsulitis may present quite similar to an individual suffering from Bursitis, however the major clinical distinguishing feature is that the range of motion noted upon examination will be generally greater in Bursitis sufferers.
- Rotator Cuff Injury: Individuals suffering from Rotator Cuff pathology may note reductions in range of motion and strength however additional imaging such as MRI and Ultrasound will rule out Frozen shoulder.
- Glenohumeral Joint Dislocation: While shoulder joint dislocation is typically the result of direct trauma and individual who has significant ligament laxity may be unknown that a dislocation has taken place. In this type of circumstance there will be apparent loss of shoulder joint movement however a step defect over the shoulder should be palpated and clearly indicate that a dislocation has occured.
ADHESIVE CAPSULITIS EXAMINATION
Currently the diagnosis off Adhesive Capsulitis (Frozen Shoulder Syndrome) is based on clinical/examination findings and patient history. Your musculoskeletal therapist, such as Chiropractor or Physiotherapist may ask you to complete one of the following outcome measures:
- Shoulder Pain & Disability Index
- Disability of Arm, Shoulder & Hand Scale
- Visual Analogue Scale
A typical shoulder region physical examination may include (but not limited to):
- Observation: your Chiropractor will observe for potential scapula winging/deformity, unlevelving of the shoulders and general posture.
- Range of motion: assessment of passive and active range of motion of the shoulder, cervical and thoracic spine to determine the extent of limited movement
- Muscle strength testing: assess surrounding muscles of the shoulder joint to ascertain if muscle weakness is apparent.
- Neurological & Orthopaedic assessment: is it essential that your health care practitioner assesses your dermatomes, myotomes and reflexes to rule of potential serious pathology involving the cervical spine and associated structures.
ADHESIVE CAPSULITIS TREATMENT
Although Adhesive Capsulitis is a self-limiting condition, it may take many years for individuals to note improvement and some sufferers may infact note permanent loss of normal range of motion. Given this, appropriate treatment to address pain, loss of movement and general function is necessary. It is generally considered that treatment intervention should consist of physical therapy, anti-inflammatory measures and exercise.
Chiropractic & Physiotherapy
Physical therapy such as provided by Chiropractors & Physiotherapist’s assist individuals with improving range of motion, reducing pain and therefore improving quality of life. Treatment that may be administered by such professionals may include:
- Mobilization of the cervical and thoracic spine and shoulder girdle complex
- Soft tissue massage to the shoulder structures to assist with pain reduction and mobility
- Postural exercise advice to assist with scapular and shoulder stability
- Physiological therapeutics such as Ultrasound, Shockwave therapy and low level laser treatment to assist with reducing inflammation
WHAT DOES THE RESEARCH TELL US?
- Individuals suffering from Adhesive Capsulitis (Frozen Shoulder) demonstrated greater improvement following high-grade shoulder mobilization techniques compared to low-grade mobilization techniques. Vermeulen, H. (2006). Comparison of high-grade and low-grade mobilization techniques in the management of Adhesive Capsulitis of the shoulder: Randomized controlled trial. Physical Therapy, 86(3); 355 – 368.
- Majority of patients presenting with Adhesive Capsulitis demonstrated clinically significant improvement following Chiropractic management consisting of cervical, thoracic and shoulder joint manipulative therapy. Murphy, F. et al., (2012). Chiropractic management of frozen shoulder syndrome using a novel technique: a retrospective case series of 50 patients. The Journal of Chiropractic Medicine, 11(4); 267 – 272.