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1
when the adhesions pull on the capsular Comparison of (N) & Abn Biomech
tissues, it is very painful
attached along the outside ring of the GH capsule
glenoid cavity and the
Normally: lax
anatomical neck of the humerus In FS: (+) tightening
(Maam Annie)
Scapulohumeral rhythm
Anatomy & Biomechanics:
Scapulohumeral rhythm Normally:
Integrated movements of the GH, ST, AC, and There is a 2:1 ratio of humerus to
SC joints that occurs in sequential fashion to scapula motion
allow full functional motion of the shoulder
complex In FS: altered; reversed
2
Affects women> men; Middle - older
aged persons > younger
Factors that have been found to
predispose a patient to idiopathic
capsulitis include diabetes (insulin
dependent), hypothyroidism, and
underlying cardiopulmonary
involvement
There is a theory that it may be caused
by an autoimmune reaction
Body begins to attack the tissues of the
body
This causes an intense inflammatory
reaction in the tissue that is under attack
Associated conditions may include:
2. Secondary
Immobilization due to injury/trauma/
Result of some other known pathology/ surgery unrelated to the shoulder
conditions Arthritis
That may cause chronic inflammation Bursitis, rotator cuff tears, or
and pain (of the tissues surrounding the impingement syndrome
joint) that make you use that shoulder Postural faults (kyphosis)
less capsular tightness Reflex sympathetic dystrophy (shoulder-
Is associated with many different hand syndrome)
underlying diagnoses Cervical disc disorders
Onset is traumatic Psychogenic disorders (clinical
Generally occurs after trauma (major or depression)
minor repetitive) or immobilization (esp. Cardiovascular disease (CVA)
after surgery) Parkinson's disease
May be provoked by chronic Insulin dependent diabetes mellitus
inflammation in the musculotendinous Hypothyroidism
or synovial tissue such as rotator cuff, Iatrogenic disorders (unforeseen/
biceps tendon or joint capsule or faulty inevitable side effect of treatment post
posture mastectomy
More commonly seen in athletes (Maam Annie)
Implication is that the problem is
worsened
Pathophysiology
3
Characterized by development of
dense adhesions & thickening of the
capsule
Inflammation of capsule
Inflammatory response
4
(+) significant capsular restrictions from Up to three intraarticular corticosteroids
adhesions injections can be used during stage 1
Stage last 2-24 mos. or longer and 2 of adhesive capsulitis to reduce
Spontaneous recovery occurs 2 years inflammation and pain facilitate
from onset rehabilitation and shorten the duration of
Surgery may be required to restore this condition
motion for some patients Postural retaining to reduce kyphosis
posture and forward humeral positioning
Stages of Frozen Shoulder should be undertaken
Aggressive ROM exercise should be
1. Stage 1
avoided until the patient pain has been
Occurs for the first 1-3 months and
adequately controlled
involve pain with shoulder Symptoms can be worsen leading the
movements but no significant
patient to immobilized his or her
glenohumeral joint ROM
shoulder thus further loss of ROM
restriction when examined under Early in rehabilitation process passive
anesthesia
joint glide and non-painful passive
2. Stage 2 ( Freezing Stage)
ROM exercise might be beneficial
Symptoms have been present for 3-
Early scapular stability and close chain
9 months and characterized by pain
rotator cuff exercise can be instituted
with shoulder motion and As the patient symptoms improve
progressive glenohumeral joint
AAROM and AROM can be added
ROM restriction in forward flexion
along with open chain and
abduction and internal rotation and
proprioceptive exercise
external rotation Most patient will have restoration of
3. Stage 3 (Frozen Stage)
normal function over 12-14 months
Symptoms have been present for 9-
period
15 months and including a In patient who do not improve after 6
significant reduction in pain but
months of non-operative treatment
maintenance of the restrictive
more aggressive treatment such capsular
glenohumeral joint ROM
hydrodilatation manipulation under
4. Stage 4 (Thawing stage)
Symptoms have been present for anesthesia and arthroscopic lysis of
adhesion can be consider
approximately 15-24 months and
ROM gradually improve (Braddom)
*Routine radiograph evaluation is usually
normal but glenohumeral joint arthrography
typically show a significant cant reduction in the
capsular movement
5
Hemarthrosis of shoulder secondary to
trauma
6
2. ROM
Internal rotation
3. HPI
5. Imaging studies
Arthrography
7
(N) Esp. scapular upward rotator muscles
Given to rule out/ exclude other (commonly lower trapezius, middle
pathology (such as underlying tumor or trapezius, and serratus anterior)
calcium deposit ) 7. Faulty postural compensations
May show osteopenia/ osteoporosis Excessive scapular protraction
secondary to disuse Excessive scapular elevation overhead
Especially in patients whose pain and reaching
motion do not improve after 3 months of
Capsular vs. Non Capsular Pattern
treatment
Capsular Pattern
MRI
LOM of pain at a joint that occurs in a
predictable pattern
Is a proportional limitation of the three
passive scapulohumeral movements
6. Lab exams It consists of a certain degree of
limitation of abduction, more limitation
ESR and C- reactive protein (CRP)
of external rotation and less limitation of
are useful to rule an inflammatory
internal rotation
arthritis or polymyalgia rheumatica
Always indicates a lesion of the joint
7. Age of patient capsule or synovial membrane
Ex. arthritis or capsulitis
(Maam Annie) It may be either an acute
synovitis or a chronic organized
Signs & symptoms: reaction of the fibrous capsule
Common Impairments
Non capsular pattern
1. Pain
dull aching Limitation of movements that does not
Lateral brachial (deltoid) area correspond to the fixed proportional/
2. Limited AROM & PROM in a predictable limitation of the capsular
"capsular pattern" pattern
ER > abduction > IR It points to a lesion of an inert (non-
Internal rotation is usually the contractile) structure that is not the
motion that takes the longest entire joint
to regain Ligamentous adhesions
3. Muscle atrophy (deltoid, rotator cuff,
biceps & triceps) Internal derangements
4. Decreased arm swing during gait
5. General muscle weakness & poor Extra-articular derangements
endurance in the GH muscles
Contractile patterns
6. Overuse of scapular muscles leading to
pain in trapezius & posterior cervical It points to a disorder of one or more
muscles contractile structures (muscle/ tendon/
tenoperiosteal insertion or innervation)
8
The passive movements are full range 2. Patients complain about inability to lift
and the endfeel is normal arm overhead, reach into the back
pocket, dress or fasten clothing behind
However,the passive their back ( i.e. fasten the bra), comb the
movements are painful at the hair, or wash the opposite shoulder
end of range and/or there is a 3. Limited ability to sustain repetitive
painful arc (1) activities