_Adhesive Capsulitis_
Summary
Fibrosis and contracture of the glenohumeral capsule (esp. anterior/inferior) producing a capsular pattern of restriction. Self-limiting but slow; management is stage-dependent.
Pathology. Adhesive capsulitis is fibrosis and contracture of the glenohumeral joint capsule (notably anterior/inferior), producing a capsular pattern of restriction. It is self-limiting but slow. Management is stage-dependent: in the painful freezing stage prioritise pain relief and gentle movement; in frozen/thawing stages prioritise progressive mobilisation and stretch to restore range.
Clinical presentation (signs & symptoms)
Deep aching shoulder pain, progressive global stiffness, marked loss of external rotation, night pain, functional limitation. Passive and active ROM equally restricted in a capsular pattern.
Assessment (Examination & Assessment)
Subjective
Gradual onset shoulder pain + progressive stiffness; night pain; difficulty reaching overhead/behind back (hair, back pocket, bra). Identify stage: freezing (painful) → frozen (stiff) → thawing. Pain scale.
Objective
Capsular pattern — greatest passive loss of external rotation, then abduction, then internal rotation. Active ROM = passive ROM (key differentiator from rotator cuff tear). Observe posture/atrophy; palpate. Screen the cervical spine.
Differentiate from
Rotator cuff tear (active < passive), glenohumeral OA, subacromial pain syndrome.
Key special tests
| Test | What a positive result indicates | |---|---| | Passive ROM — capsular pattern | external rotation most limited > abduction > internal rotation | | Active vs passive ROM comparison | active = passive (key differentiator from a cuff tear) | | End-feel assessment | firm capsular end-feel |
Red flags & when to refer
- Fracture or dislocation
- Malignancy (unremitting night pain, systemic features)
- Full-thickness rotator cuff tear (active ROM much worse than passive)
- Neurological cause (e.g., Parsonage–Turner syndrome)
Contraindications & precautions
- Aggressive mobilisation/stretch in the irritable freezing stage worsens pain — match grade to irritability.
- Dry needling around the shoulder girdle: caution with depth over the thorax (pneumothorax risk); avoid neurovascular structures; consent & hygiene.
- General: rule out fracture, dislocation, malignancy and full-thickness cuff tear before mobilising.
Treatment protocol
Session structure & time scales
- Pre-assessment + prep (10 min): ROM (active = passive), capsular pattern, stage.
- Soft tissue — periscapular, cuff, upper trap, pec (12–15 min).
- Graded glenohumeral mobilisations (respect stage) (8 min).
- Dry needling — periscapular trigger points (8 min).
- Electrotherapy — US / thermal (8 min).
- Gentle ROM + pendular demo (5 min).
- Reassessment + home programme (5 min).
Modalities & rationale
| Modality / technique | Rationale (why it is used for this pathology) | |---|---| | Soft tissue (periscapular/cuff/pec) | reduces protective guarding and secondary tightness. | | Graded GH mobilisations (Maitland) | gentle (grade I–II) in irritable freezing stage for pain; progress to grade III–IV in frozen/thawing to restore glide (Banks, 2013). | | Dry needling | eases periscapular trigger points contributing to pain (Sharkey, 2017). Depth caution. | | Electrotherapy / thermal | US and heat for pain relief and to precede stretch (Watson, 2008). | | Pendular & graded ROM | maintains mobility within tolerance across stages. |
Loading & exercise progression
Stage-matched. Freezing (irritable): gentle grade I–II mobilisations, pendular, pain relief. Frozen/thawing: grade III–IV mobilisations, progressive stretch and active ROM to restore range.
Home care / self-management
Pendular exercises, active-assisted ROM (pulley, table/wall slides) within pain, heat before exercise, reassurance about natural history, avoid painful end-range forcing in freezing stage.
Outcome measures & re-assessment
- Pain scale (NPRS 0–10) pre/post; night pain trend.
- Re-measure external rotation & abduction ROM.
- Compare active vs passive change.
- Function: hand-behind-back / overhead reach.
Anatomy reference
| Structure | Origin | Insertion | Action | |---|---|---|---| | GH joint capsule | — (contracture/thickening, esp. anterior/inferior) | — | the primary restricted structure | | Supraspinatus | supraspinous fossa | greater tubercle (superior facet) | initiates/assists abduction | | Infraspinatus | infraspinous fossa | greater tubercle (middle facet) | external rotation | | Teres minor | lateral border of scapula | greater tubercle (inferior facet) | external rotation | | Subscapularis | subscapular fossa | lesser tubercle | internal rotation | | Deltoid | clavicle, acromion, spine of scapula | deltoid tuberosity | abduction (flexion/extension) |
Clinical reasoning (Q&A for the system)
_These question–answer pairs encode the expected clinical reasoning for this condition. Use them to justify decisions and to check generated plans._
Q: How do you differentiate frozen shoulder from a rotator cuff tear? A: In adhesive capsulitis active ROM equals passive ROM (both restricted in a capsular pattern). In a cuff tear active is worse than passive.
Q: Describe the capsular pattern of the shoulder. A: External rotation is most limited, then abduction, then internal rotation.
Q: How does your treatment change across the stages? A: Freezing (painful/irritable): gentle grade I–II mobilisations and pain relief. Frozen/thawing (stiff): progress to grade III–IV mobilisations and stretch to restore range.
Q: Give the rotator cuff muscles and their main actions. A: Supraspinatus — abduction/initiation; infraspinatus and teres minor — external rotation; subscapularis — internal rotation.
Q: What are your key contraindications here? A: Don't force end-range in the irritable freezing stage; control needling depth around the shoulder girdle (pneumothorax risk); rule out fracture, dislocation and full-thickness cuff tear first.
References
- Banks, K. (2013) _Maitland's Peripheral Manipulation Management._ Elsevier.
- Banks, K. (2013) _Maitland's Vertebral Manipulation Management._ Elsevier.
- Sharkey, J. (2017) _The Concise Book of Dry Needling._ Lotus Publishing.
- Watson, T. (2008) _Electrotherapy: Evidence Based Practice._ Elsevier.
- Clarkson, H. M. (2013) _Musculoskeletal Assessment._ 3rd edn. Lippincott.
- TODO: add a condition-specific loading-protocol reference (from module notes), Harvard format.