Download Adhesive-Capsulitis-Handout

The Stiff Shoulder
Normal Anatomy
• The glenohumeral joint
is surrounded by a
capsule
• Parts of the capsule are
thicker and are
identified as ligaments
Restraints To Motion
• Limitation in External
rotation at 0°
– Coracohumeral Ligament
– Superior Glenohumeral
Ligament
• Limitation in External
Rotation at 45°
– Middle glenohumeral
ligament
• Limitation in External
Rotation at 90°
– Anterior Band of Inferior
Glenohumeral Ligament
Restraints To Motion
• Limitation in Internal
rotation at 0° and 45 °
– Posterior Capsule
• Limitation in Internal
Rotation at 90°
– Posterior Band of
Inferior Glenohumeral
Ligament
Pathophysiology
• No agreement on
pathophysiology
• Elevated cytokines
levels cause continued
inflammation and
fibrosis
• Presence of
inflammation disputed
• Agreement on presence
of capsule fibrosis
Classification
Classification
Associated Pathologies
•
•
•
•
•
Diabetes
Thyroid
Rheumatoid arthritis
Scleroderma
Cardiovascular disease
Stages
Stage
Name
Time Frame
Pain
ROM
Arthroscopic
Findings
1
Painful
0 – 3 Months
At end range
90-100%
Synovitis
No capsular
fibrosis
2
Adhesion
3 – 6 Months
Severe
Globally
Restricted
Synovitis, Inferior
capsule adheres to
humerus
3
Frozen
6 – 12 Months
At end of
Globally
available range Restricted
Burned out
synovitis, fibrosis
of capsule
4
Thawing
15 – 24 Months
At end of
Gradually
available range Increases
Information not
available
Subjective
• Dependent on stage
• Insidious onset (can be traumatic or post
operative)
• Gradual increase in pain
• Disturbed sleep
• Restricted painful range of movement
Subjective
More Night
Pain
=
More Synovitis
More Pain
=
More Synovitis
More Stiffness
=
Less Synovitis,
More Fibrosis
Objective
•
•
•
•
•
Dependent on stage
Global loss ROM
External Rotation Restriction
Active = Passive ROM
Capsular End Feel or Muscle Spasm End Feel
Further Investigation
• MRI can be used to rule out other pathology
• Otherwise diagnosis is made clinically
Conservative - Management
•
•
•
•
•
•
Dependent on stage and irritability
Physiotherapy is aimed at restoring MOBILITY
Soft tissue work is used to prepare tissues
Joint Mobilisations are KEY
Heat is applied in all stages
Strengthening can be continued once range of
movement allows
Conservative - Management
• Highly Irritable, Severe Pain, Lots of Night Pain,
End Feel due to Muscle Spasm
– Soft tissue work
– Low Grade Mobilisation
– Regular light Active Range of Movement HEP
• Minimal Irritability, Pain at end range, Capsular
End Feel
– Aggressive Mobilisation
– Low Load, Long Duration Stretching
Conservative - Management
• Know your capsular
pattern and
Arthrokinematics to
target specific parts of
the joint
Surgical - Management
• Manipulation Under Anaesthetic
• Arthroscopic Capsular Release