On-line CEUs

TIP OF THE MONTH: May/June 2005
Adhesive Capsulitis of the Shoulder
Katherine Bagnato, OTC, ATC

Adhesive capsulitis is an inflammatory reaction of the shoulder joint that causes decreased range of motion and pain. In layman’s terms, it is called a “frozen shoulder”. You may know of patients, family members, or friends that have had pain in their shoulder and difficulty raising the arm that started slowly and for no apparent reason. Adhesive capsulitis has no known etiology and in most cases is not caused by an acute severe injury. Over a short time, it becomes difficult to move the upper extremity without extreme pain. The patient has pain with all movements, difficulty reaching for objects, and problems dressing, especially reaching behind. Due to the pain with movements, the patient is unwilling to perform range of motion and therefore the shoulder becomes “stuck” or frozen. The capsule of the shoulder becomes adhered to tissues and without medical and therapeutic intervention; the shoulder becomes immobile over time. It is a condition common in diabetics.

A subtle irritation that causes the shoulder joint fibers to become injured causes adhesive capsulitis. Because of this injury, pain begins to intensify and the shoulder reacts by forming scar tissue adhesions. These adhesions begin to form within the joint capsule and make movement of the shoulder increasingly difficult. When the patient attempts to move the shoulder, pain develops when the adhesions tear. Because of the severe pain, the patient decreases range of motion and use of the shoulder. Adhesive capsulitis follows a predictable pattern if not treated. The first phase of a “frozen shoulder” is the pain stage. The pain in the shoulder/upper extremity becomes worse. This process occurs over a three to four month time. The second phase is a plateau stage. The pain in the shoulder plateaus – does not get worse or better. This process occurs over a three to six month time. The last phase is a stiff stage. The pain decreases in the shoulder, but it is now very stiff from the lack of range of motion and movement from the previous six to nine months of pain.

Medical and therapeutic intervention can decrease the symptoms and longevity of this debilitating condition. If a patients presents within the first phase and in severe pain, an injection of corticosteroid is offered. This is a local injection to attempt to reduce to inflammation of the capsule, thus allowing the patient to begin aggressive physical therapy to gain range of motion. The patient is educated on the importance of moving the shoulder to prevent the “stiffness”. If the patient presents in the second or third phase, aggressive physical therapy and oral anti-inflammatory medication are prescribed. Physical therapy is critical in order to stretch the adhesions and re-establish a normal range of motion in the shoulder and is prescribed in all phases of adhesive capsulitis. A great understanding on the patient’s behalf of their commitment to the constant attention to compliance is needed and should be stressed during office evaluation. In some cases adhesive capsulitis may take 6 months to 1 year of conservative treatment to resolve. The orthopaedic physician monitors progression of range of motion and reduction of pain by following patients closely with regular evaluations. The patient’s goal is to become painfree and functional.

When a patient reaches an unacceptable plateau in range of motion, particularly not equal to the unaffected extremity, surgical intervention may be introduced consisting of an arthroscopic capsular release. This procedure involves evaluating the shoulder complex through the arthroscope and making an incision around the capsular ring of the shoulder to relieve the adhesions and gain full range of motion. It is important post-operatively to continue aggressive physical therapy to keep this range of motion. Many patients who have failed conservative treatment have had successful results from this procedure. There is no reason a patient needs to live with this type of shoulder pain and debilitation. Patient education of signs and symptoms, aggressive treatment options and careful medical attention can greatly reduce and even eliminate this condition.

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(period to obtain CEUs on-line for this article expired January 6, 2006).