FROZEN SHOULDER
OTHER NAME
Adhesive capsulitis
Shoulder periarthritis
Obliterative bursitis,
Adherent bursitis
Pericapsulitis
DEFENITION
FS is not an accurate diagnosis, but
rather a description of the major
symptom, which is lack of movement
LOM is directly attributed to structural
changes in periarticular tissues
Capsular contracture and adhesion
formation
GH capsule tightening & reversed
scapulohumeral rhythm
Up to 30% of individuals develop the
condition in the opposite shoulder
(Maam Annie)
Characterized by painful restricted
shoulder ROM in patient normal
radiograph
(Braddom)
The loss of range is multiplanar, with
external rotation and abduction being
the most affected.
The syndrome is typically painful to
treat and has a natural recovery that can
be prolonged lasting up to 2 years.
(De Lisa)
Epidemiology
Female
Onset 40-65 years old
Affects 10-20% of diabetics
Self-limiting
Spontaneous resolution after 1-3 years
and motion is regained
2-5% in general population 2-4x
common in women
Onset 40-60 years old
(Braddom)
Causes
Idiopathic condition associated with
Diabetes mellitus
Inflammatory arthritis
Trauma
Prolonged immobilization
Thyroid disease
CVA
MI
Autoimmune disease
(Braddom)
PATHOLOGICAL EVALUATION
Perivascular inflammation but
predominant abnormality fibroblastic
proliferation with incase collagen and
nodular band formation
(Bradddom)
Anatomy & Biomechanics:
Glenohumeral joint capsule
Loose
Has a considerable amount of slack, so
that the shoulder is unrestricted as it
moves through its large range of motion
Surrounded and reinforced by muscles
tendons, and ligaments which are
largely responsible for keeping the
adjoining parts together
Lax inferiorly
Contained within are bursa & tendon of
biceps etc
Richly innervated
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 when the adhesions pull on the capsular
tissues, it is very painful
attached along the outside ring of the
glenoid cavity and the
anatomical neck of the humerus
(Maam Annie)
Anatomy & Biomechanics:
Scapulohumeral rhythm
Integrated movements of the GH, ST, AC, and
SC joints that occurs in sequential fashion to
allow full functional motion of the shoulder
complex
2:1 ratio of glenohumeral to scapulothoracic
movement
Initial 30 degrees of abduction/flexion is
primarily glenohumeral
Remaining elevation
Glenohumeral and scapulothoracic
joints move simultaneously
Purposes of Scapulohumeral rhythm:
1. Allows for greater overall shoulder
range of motion (ROM)
2. Preserves length tension relationship of
the glenohumeral muscles
3. Prevents impingement between the
humerus and acromion
Maintains optimal contact
between the humeral head and
the glenoid fossa
Note: Rotation of the scapula is associated with
5 of elevation at the SC joint and 25 of
rotation at the AC jt.
0-30 degrees - GH
30-90 degrees GH (30)* & ST (30)*
90-180 degrees - GH (60) & ST (30)
Total shoulder ROM= 120 degrees GH & 60
degrees ST
Comparison of (N) & Abn Biomech
GH capsule
Normally: lax
In FS: (+) tightening
Scapulohumeral rhythm
Normally:
There is a 2:1 ratio of humerus to
scapula motion
In FS: altered; reversed
Movement is much more excessive at
the scapula versus the GH joint (esp
during abduction)
This can also suggest rotator cuff tear
Maybe signs of guarding or
compensation
Determined by the examiner by
observing the movement of the scapula
in relation to the humerus and during
abduction
(Maam Annie)
Etiology:
Types & Predisposing Factors
1. Primary (Idiopathic)
Cause is unknown
Patients develop the condition in the
absence of preceding trauma
Develops spontaneously
More common
Usual onset begins between ages 40 -60
Has an insidious onset
Pain restriction followed by gradual
stiffness with less pain
Inflammation and pain can cause reflex
inhibition of the shoulder muscles
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 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

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 Characterized by development of
dense adhesions & thickening of the
capsule
The joint capsule is richly innervated,
so when the adhesions pull on the
capsular tissues, it is very painful
Inflammation of capsule
Inflammatory response
Thickening, fibrosis and scarring develops
Tightness & adhesions
LOM
Altered scapular and GH joint mechanics
Stages of Frozen Shoulder
1. Freezing (reactive phase)
characterized by pain even at rest (dull
aching)
Pain increases with movement and is
often worse at night
There is a progressive loss of motion
with increasing pain (2-3 wks after
onset)
Most patients will position the arm in
adduction and internal rotation
This stage lasts approximately 10-36
weeks
2. Frozen (Stiffening stage)
Characterized by pain only with
movement (pain begins to diminish)
Significant adhesions & LOM with
substitute motion of the scapula
Progressive loss of ROM and decreased
function are noted
ROM is now much more limited, as
much as 50% less than in the other arm
Restricted motion in all planes
Activities of daily living become
severely restricted
Patients complain about inability to
reach into the back pocket, fasten the
bra, comb the hair, or wash the opposite
shoulder
Atrophy of the deltoid, rotator cuff,
biceps & triceps occurs
This stage may last 4 to 12 months
3. Thawing (Resolving phase)
There is no more pain or synovitis
Pain is usually localized in the deltoid
region
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 (+) significant capsular restrictions from
adhesions
Stage last 2-24 mos. or longer
Spontaneous recovery occurs 2 years
from onset
Surgery may be required to restore
motion for some patients
Stages of Frozen Shoulder
1. Stage 1
Occurs for the first 1-3 months and
involve pain with shoulder
movements but no significant
glenohumeral joint ROM
restriction when examined under
anesthesia
2. Stage 2 ( Freezing Stage)
Symptoms have been present for 3-
9 months and characterized by pain
with shoulder motion and
progressive glenohumeral joint
ROM restriction in forward flexion
abduction and internal rotation and
external rotation
3. Stage 3 (Frozen Stage)
Symptoms have been present for 9-
15 months and including a
significant reduction in pain but
maintenance of the restrictive
glenohumeral joint ROM
4. Stage 4 (Thawing stage)
Symptoms have been present for
approximately 15-24 months and
ROM gradually improve
*Routine radiograph evaluation is usually
normal but glenohumeral joint arthrography
typically show a significant cant reduction in the
capsular movement
Up to three intraarticular corticosteroids
injections can be used during stage 1
and 2 of adhesive capsulitis to reduce
inflammation and pain facilitate
rehabilitation and shorten the duration of
this condition
Postural retaining to reduce kyphosis
posture and forward humeral positioning
should be undertaken
Aggressive ROM exercise should be
avoided until the patient pain has been
adequately controlled
Symptoms can be worsen leading the
patient to immobilized his or her
shoulder thus further loss of ROM
Early in rehabilitation process passive
joint glide and non-painful passive
ROM exercise might be beneficial
Early scapular stability and close chain
rotator cuff exercise can be instituted
As the patient symptoms improve
AAROM and AROM can be added
along with open chain and
proprioceptive exercise
Most patient will have restoration of
normal function over 12-14 months
period
In patient who do not improve after 6
months of non-operative treatment
more aggressive treatment such capsular
hydrodilatation manipulation under
anesthesia and arthroscopic lysis of
adhesion can be consider
(Braddom)

Treatment during stage 1 and 2 of

adhesive capsulitis include physical
modalities, analgesic and activity
modification to reduce pain and
inflammation

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 Hemarthrosis of shoulder secondary to
trauma

Other Soft-Tissue Disorders about the

Differential Diagnosis
Shoulder
Rule out other possible disease or pathology
Tendinitis of the rotator cuff
1. Organ pathology Tendinitis of the long head of biceps
Subacromial bursitis
Visceral Origin Impingement
Referred pain Suprascapular nerve impingement
Thoracic outlet syndrome
2. Other possible soft tissue & bone injury in the
shoulder Joint Disorders

Chronic locked posterior dislocation Degenerative arthritis of the AC joint

* Prior to making the diagnosis of Degenerative arthritis of the
frozen shoulder be sure to rule the glenohumeral joint
possibility of a chronic locked posterior Septic arthritis
dislocation Other painful forms of arthritis
Rotator cuff tear
Bone Disorders
3. Cervical spine pathology
Avascular necrosis of the humeral head
Cervical disc disease Metastatic cancer
Paget disease
4. Some other pathology
Primary bone tumor
Arthritis (ex. polymyalgia rheumatica-> Hyperparathyroidism
which is usually associated w/ elevated
Cervical Spine Disorders
sedimentation rate)
Cancer (pancoast tumor) Cervical spondylosis
Somatic (psychological) Cervical disc herniation
Complex regional pain syndrome (RSD) Infection

8 Categories of conditions that should be Intrathoracic Disorder

considered in the differential diagnosis of
Frozen Shoulder Diaphragmatic irritation
Pancoast tumor
Trauma Myocardial infarction
Fractures of the shoulder region Abdominal Disorde
Fractures anywhere in the upper
extremity Gastric ulcer
Misdiagnosed posterior shoulder Cholecystitis
dislocation Subphrenic abscess

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 2. ROM

Depends on the stage of FS

In general: (+) global LOM of both
active and passive motion
(+) Apley scratch test
Helps identify which portion of the
capsule is most affected

External rotation w/ arm adducted

Tests for contracture of the antero-

superior portion of the capsule
LOM on passive movement in this
Psychogenic position is a hallmark of FS

External rotation w/ arm abducted

Tests for contracture of the antero-

inferior portion of the capsule

Internal rotation

Tests for contracture of

posterior capsule

3. HPI

Traumatic vs. non-traumatic

Onset and duration of symptoms

4. Other Medical hx of patient (as well

as lifestyle)

DDM, Heart conditions etc

5. Imaging studies

Arthrography

Gold standard for diagnosis

Demonstrates marked contracture of
joint capsule and obliteration of the
axillary fold
Evaluation & Diagnosis Will show a decrease in capsular joint
volume (<10 ml)
1. Location of pain
X-ray
Lateral

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 (N)
Given to rule out/ exclude other
pathology (such as underlying tumor or
calcium deposit )
May show osteopenia/ osteoporosis
secondary to disuse
Especially in patients whose pain and
motion do not improve after 3 months of
Capsular vs. Non Capsular Pattern
treatment
Capsular Pattern
MRI
6. Lab exams
ESR and C- reactive protein (CRP)
are useful to rule an inflammatory
arthritis or polymyalgia rheumatica
7. Age of patient
(Maam Annie)
Signs & symptoms:
Common Impairments
Non capsular pattern
1. Pain
dull aching
Lateral brachial (deltoid) area
2. Limited AROM & PROM in a
"capsular pattern"
ER > abduction > IR
Internal rotation is usually the
motion that takes the longest
to regain
3. Muscle atrophy (deltoid, rotator cuff,
biceps & triceps)
4. Decreased arm swing during gait
5. General muscle weakness & poor
endurance in the GH muscles
Contractile patterns
6. Overuse of scapular muscles leading to
pain in trapezius & posterior cervical
muscles
Esp. scapular upward rotator muscles
(commonly lower trapezius, middle
trapezius, and serratus anterior)
7. Faulty postural compensations
Excessive scapular protraction
Excessive scapular elevation overhead
reaching
LOM of pain at a joint that occurs in a
predictable pattern
Is a proportional limitation of the three
passive scapulohumeral movements
It consists of a certain degree of
limitation of abduction, more limitation
of external rotation and less limitation of
internal rotation
Always indicates a lesion of the joint
capsule or synovial membrane
Ex. arthritis or capsulitis
It may be either an acute
synovitis or a chronic organized
reaction of the fibrous capsule
Limitation of movements that does not
correspond to the fixed proportional/
predictable limitation of the capsular
pattern
It points to a lesion of an inert (non-
contractile) structure that is not the
entire joint
Ligamentous adhesions
Internal derangements
Extra-articular derangements
It points to a disorder of one or more
contractile structures (muscle/ tendon/
tenoperiosteal insertion or innervation)
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 The passive movements are full range
and the endfeel is normal
However,the passive
movements are painful at the
end of range and/or there is a
painful arc (1)
1 Inert structures characterised by pain
at the end of passive range and /or a
painful arc
1. Chronic AC - strain
2. Chronic Subdeltoid Bursitis
Or the passive movements are
completely painless but there exists a
remarkable discrepancy between the
active and the passive elevation (2)
2 Neurological lesions characterised by
a limitation of the active elevation and a
full and painless passive elevation
1. Lesion of the Long Thoracic Nerve
2. Lesion of the Accessory Nerve
FunctioAnal Limitations
1. Difficulty in ADL activities
2. Patients complain about inability to lift
arm overhead, reach into the back
pocket, dress or fasten clothing behind
their back ( i.e. fasten the bra), comb the
hair, or wash the opposite shoulder
3. Limited ability to sustain repetitive
activities
Rehabilitation Concerns
The primary concern of rehabilitation is
proper differential diagnosis
The type of rehab management depends
on the stage of pathology when
intervention is started
The role of the physical therapy is to
hasten the progression through the
stages and limit the severity of the
earlier stages so that the patient can
move to the final stages as quickly as
possible with the least amount of
impairment, activity limitation, and
participation restrictions
early intervention can reduce the overall
duration of the condition