What is Adhesive Capsulitis

Adhesive Capsulitis ( Frozen shoulder ) is a benign, self-limiting condition of unknown etiology characterised by painful and limited active and passive glenohumeral range of motion of = 25% in at least two directions most notably shoulder abduction and external rotation.

Adhesive capsulitis, commonly referred to as frozen shoulder, is associated with synovitis and capsular contracture of the shoulder joint and can be classified as either primary or secondary. In clinical practice it can be hard to differentiate adhesive capsulitis from other shoulder pathologies. Since the physical therapy management of adhesive capsulitis is much different than that of other shoulder pathologies it can be detrimental to the patient if they are misdiagnosed. Therefore, it is important for the clinician to be aware of the hallmarks of frozen shoulder and recognise the clinical phases that are specific to this condition.

Medical Management
Although Adhesive Capsulitis is a self-limiting condition, it can take up to two to three years for symptoms to resolve and some patients may never fully regain full motion. Treatment for pain, loss of motion, and limited function rather than take the wait-and-see approach is therefore important. Various interventions have been researched that address the treatment of the synovitis and inflammation and modify the capsular contractions such as oral medications, corticosteroid injections, distension, manipulation, and surgery. Even though many of these treatments have shown significant benefits over no intervention at all, definitive management regimens remain unclear. It is suggested that the primary treatment for adhesive capsulitis should be based around physical therapy and anti-inflammatory measures, these outcomes, however, are not always superior to other interventions.

Corticosteroid injections are often used to manage inflammation as it is understood that inflammation is a key factor in the early stages of the condition. The injections aim to reduce the painful synovitis occurring within the shoulder. This can limit the development of fibrosis and adhesions within the capsule, potentially shortening the natural history of the disease. Hence they are thought to be more useful in the early, painful and freezing stage of the condition due to the involvement of inflammation, rather than in the latter stages when fibrous contractures are more apparent.

For the treatment of adhesive capsulitis, patient education is essential in helping to reduce frustration and encourage compliance. It is important to emphasise that although full range of motion may never be recovered, the condition will spontaneously resolve and stiffness will greatly reduce with time. It is also helpful to give quality instructions to the patient and create an appropriate home exercise program that is easy to comply with as daily exercise is critical in relieving symptoms.

Modalities
Modalities, such as hot packs, can be applied before or during treatment. Moist heat used in conjunction with stretching can help to improve muscle extensibility and range of motion by reducing muscle viscosity and neuromuscular mediated relaxation. Manual techniques and exercise should only be progressed as the patient's irritability reduces. Patient response to treatment should be based on their pain relief, improved satisfaction, and functional gains, rather than restoration of range of motion. Usually, patients are discharged when significant pain reduction is reached, a plateau of motion gains are noticed for a period of time, and after improved functional motion and satisfaction have reached their peak. Progression for stretching via dynamic splinting is based on patient tolerance, as well.