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Adhesive Capsulitis

Adhesive Capsulitis. By: AJ Francioni 3 rd Year DPT – UNC Chapel Hill With the assistance of Dr. McMorris. Learning Objectives. Recognize at least 3 risk factors for Adhesive Capsulitis Recognize at least 3 evaluative tools to diagnose Adhesive Capsulitis

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Adhesive Capsulitis

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  1. Adhesive Capsulitis By: AJ Francioni 3rd Year DPT – UNC Chapel Hill With the assistance of Dr. McMorris

  2. Learning Objectives • Recognize at least 3 risk factors for Adhesive Capsulitis • Recognize at least 3 evaluative tools to diagnose Adhesive Capsulitis • Be able to identify the phases of Adhesive Capsulitis • Be able to identify at least 3 treatment ideas for Adhesive Capsulitis

  3. Adhesive Capsulitis • GHJ capsular fibrosis with chronic inflammation • Primary • No specific, precipitating event • (Believed) chronic inflammation with fibroblastic proliferation • Secondary • After surgery or injury • Potential associated conditions • Diabetes, RC injury, CVA, cardiovascular disease, thyroid • Incidence = 5-percent of general population1 • As much as 20-percent for people with diabetes1

  4. Anatomy to Consider2 • GHJ encased by capsule, which has 2 layers • External = dense, fibrous connective tissue • Inner = protein collagen • Synovial membrane • if fluid is underproduced  ROM loss • Capsule is strongest superiorly  restricts rotation • Ligaments thicken capsule anteriorly  restricts external rotation • Capsular Pattern = ER > AB > IR • Common finding through imaging = coracohumeral ligament becomes stiffer

  5. Postero-Inferior view of shoulder dissection to demonstrate the anterosuperior glenohumeral capsule.3

  6. Predisposing Factors • Middle age (40-59 years) 4 • Female4 • Diabetes Mellitus1 • Thyroid disease1 • Trauma1 • Autoimmune disease1 • Cerebrovascular disease, CAD, MI1 • Sedentary lifestyle5 • Past h/o Adhesive Capsulitis • Prolonged immobilization2 • Patient Education • Modifiable Risk Factors • Level of Complexity • Adherence to HEP

  7. Pathophysiology • Inflammation + Fibrosis = pain and stiffness • Accepted pathology • Contracture of GH capsule1 • Loss of synovial layer1 • Adhesions of axillary tissue to itself1 • Decreased capsular volume1 • Fascial restrictions, muscle tightness, and trigger points • Current Hypothesis = inflammation in joint capsule and synovial fluid allow for fibrosis and adhesions in synovial lining4

  8. Glenohumeral capsule during the “frozen” phase of adhesive capsulitis6

  9. Differential Diagnosis1,4 • Septic arthritis • Fracture • Rotator Cuff pathology • GH arthrosis • Shoulder impingement • Cervical radiculopathy • Chronic Regional Pain Syndrome • Shoulder Girdle tumors • Tendonitis/bursitis • Fibromyalgia • Disease of digestive system

  10. Four Stages • Stage 1 = up to 3 months • Stage 2 = Painful “Freezing” Stage  lasts from 3-9 months4 • Stage 3 = “Frozen” Stage  lasts from 9-15 months4 • Stage 4 = “Thawing” Stage  lasts from 15-24 months4

  11. Stage 1 • Up to 3 months • Sharp pain at end of ROM • Can be mistaken for impingement d/t greater motion still available • Achy pain at rest • Sleep disturbance

  12. Stage 2 – Freezing • Lasts 3 to 9 months1 • Inflammation/synovitis1 • Present with diffuse shoulder pain or stiffness4 • More active at night • Gradual loss of motion d/t pain

  13. Stage 3 - Frozen • Lasts 9 to 15 months4 • Pain and ROM loss d/t adhesions and synovial proliferation1 • Capsular Pattern = ER > AB > IR Stage 4 – Thawing • Lasts 15-24 months4 • Recovery phase with gradual return of ROM • 20-50 percent of patients will have lasting symptoms past this phase1 • Pt education for adherence and follow-through

  14. Evaluation and Examination • Objective • Clear cervical spine • Active and Passive ROM • Compare sides • Strength • “Shrug sign” with GH elevation • Special Tests:4 • Neer • Hawkins-Kennedy • Outcome Measures Signs and Symptoms • Gradual onset of pain  progressively worse • Guarding or protect it by reducing movement • Difficulty with UE focused tasks • Sleep disturbance • Night pain

  15. Outcome Measures7 • Self-reported measures asking about ADL’s and functional tasks • Disabilities of the Arm, Shoulder, and Hand (DASH) • American Shoulder and Elbow Surgeons shoulder scale (ASES) • Shoulder Pain and Disability Index (SPADI) • Reaching overhead • Sleeping on affected side • Washing hair • Carrying heavy object

  16. Conservative Interventions • NSAIDS • Oral corticosteroids • Modalities to relieve inflammation • Physical therapy

  17. Physical Therapy Painful “Freezing” Stage • PROM to maintain existing ROM and relieve muscle involvement6 • Postural positioning8 • Grade I/II mobs and long axis distraction1,4

  18. Physical Therapy Frozen and Thawing • AAROM8 • Capsular stretching1 • Progressive resistance training in pain-free range4 • HEP • Stretching8 • Scapular and RC strengthening

  19. Referrals and Discharge • Orthopedic specialist • No improvements of symptoms or functional mobility within 6 months9 • Educate patient on expectations • Co-morbidities can affect perceived outcomes and timeliness of progress • Long-term disability 10-20 percent4 • Persistent Symptoms 30-60 percent4 • Educate on importance of persistence with HEP • Consider the biopsychosocial model when treating

  20. Procedural Interventions • GH intra-articular corticosteroid injection • Fast relief by reducing inflammation, but effects may only last 4-6 weeks 7 • Hydrodilation • Inject large volume of fluid to increase intracapsular volume and stretch capsule 1,4,6 • Manipulation under anesthesia • Capsule or scar tissue stretches or tears6 • Arthroscopic surgery • Risk d/t period of immobilization required6

  21. The Interactive Part of Learning Objectives • List at least 3 risk factors for Adhesive Capsulitis • List at least 3 evaluative tools to diagnose Adhesive Capsulitis • Explain the phases of Adhesive Capsulitis • Provide at least 3 treatment ideas for Adhesive Capsulitis

  22. References • Le HV, Lee SJ, Nazarian A, Rodriguez EK. Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments. Shoulder Elbow 2017;9(2):75-84. doi:10.1177/1758573216676786. • Carmichael SW, Hart DL. Anatomy of the shoulder joint. J. Orthop. Sports Phys. Ther. 1985;6(4):225-228. doi:10.2519/jospt.1985.6.4.225. • Duke Anatomy - Lab 16: Upper & Lower Limb Joints. Available at: https://web.duke.edu/anatomy/lab16/lab16.html. Accessed December 4, 2018. • St Angelo JM, Fabiano SE. Adhesive Capsulitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2018. • Rauoof MA, Lone NA, Bhat BA, Habib S. Etiological factors and clinical profile of adhesive capsulitis in patients seen at the rheumatology clinic of a tertiary care hospital in India. Saudi Med J 2004;25(3):359-362. • Frozen Shoulder - Adhesive Capsulitis - OrthoInfo - AAOS. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/frozen-shoulder/. Accessed December 4, 2018. • Kelley MJ, Shaffer MA, Kuhn JE, et al. Shoulder pain and mobility deficits: adhesive capsulitis. J. Orthop. Sports Phys. Ther. 2013;43(5):A1-31. doi:10.2519/jospt.2013.0302. • Chan HBY, Pua PY, How CH. Physical therapy in the management of frozen shoulder. Singapore Med J 2017;58(12):685-689. doi:10.11622/smedj.2017107. • Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am AcadOrthopSurg 2011;19(9):536-542.

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