What is it and what are the symptoms?
Adhesive Capsulitis involves the contracture of the capsule surrounding the Glenohumeral joint (Main shoulder joint) and the Coracohumeral ligament in the shoulder.
Adhesive Capsulitis is an extremely painful condition which causes severe restriction in the shoulder. This restriction can be either in all or select movement directions. The condition often affects both shoulders at some point in time, with the second shoulders onset coming between 6 months and 7 years after the initial onset in the first.
Sufferers generally experience pain over the whole general shoulder area, have a limited range of motion and reduced functionality which can generally last anywhere from 1 to 24 months (Page and Labbe, 2010).
How common is it?
The true incidence of Adhesive Capsulitis is unknown, scientific literature however proposes an incidence of around 2-5% in the general population (Hsu, et al. 2011). Many people suffering from Adhesive Capsulitis fail to report their pain due to the gradual onset and their busy life schedules. Adhesive Capsulitis most commonly affects women aged between 40 and 60 years, but can also affect males within the same age range; no differences exist between ethnicities.
The condition usually goes through three phases,
Starting with the painful or ‘‘freezing,’’ phase, in which the shoulder suffers from a progressive, involuntary stiffness. Pain is first noted with activities such as reaching and lifting. Typically, pain precedes the restriction in motion but in some instances the loss of normal motion may be the first symptom, with full movement of the arm away from the body being restricted.
The freezing phase is followed by the stiff or ‘‘frozen’’ phase where pain gradually decreases, but a reduction in the shoulders range of motion continues to affect you. This phase can last anywhere from 4 to 12 months.
The third and final stage is termed the recovery or ‘‘thawing’’ phase, this involves the gradual and in the vast majority of cases a spontaneous improvement of shoulder mobility and function. This can last over the 5 to 26 month period with a longer freezing phase associated with a longer thawing phase. The full duration of the issue can last anywhere from 9 months to 3.5 years, with an average being 30 months.
What might cause your pain?
Adhesive Capsulitis is classified as either as Primary or Secondary. Primary is where there are no findings in a person’s history or examination which explain the onset with it often coming out of the blue. Primary Adhesive Capsulitis is reported in the literature to have links with other medical issues a person may have. A systematic review from Hsu. et al.(2011) has documented possible relationships to the immune system, biochemical, or hormonal imbalances. Secondary adhesive capsulitis most commonly is triggered by a mild injury to the shoulder or develops from known causes of stiffness and immobility, such as previous shoulder trauma or surgery
|Direct trauma / injury||22% of patients suffered an injury first.|
|Neck / Shoulder surgery||31/44 patients|
|Diabetes||4.3 – 10.8% of patients|
|ATCH hormone deficiency||Rare|
|Cardiac Disease||3.3% in males|
|Stroke||50% within first year with a hemiplegic arm.|
|Neurosurgery||25.3% undergoing Neurosurgery|
|Aneurism surgery||41% undergoing acute surgery|
|Malignancy (Cancer)||9/60 patients in a scientific review had Adhesive Capsulitis|
|High Cholesterol||17% incidence|
|Drug use||Various medications can generate Adhesive Capsulitis|
|Dupuytren||45 – 52% of those with Dupuytren’s|
(Table adapted from Hsu, et al. 2011).
What are the key factors / treatment options to address?
Xray – An Xray following consult with your Physiotherapist is the first course of action to rule out other more serious causes of the restriction in your shoulder. You should not worry these other causes are rare.
However, if you have any history of Cancer, symptoms of being recently unwell with fever, malaise or lost significant weight in a short time please let your Physiotherapist know at your initial consult.
Pain management – After an Xray the first step is to get the pain under control, doing so through reduction of load in the shoulder, pain medication, massage and manual therapy. Activities overhead / into restricted ranges or with increased pulling movements need to be reduced, whilst a reduction in the tension of the tight shoulder complex musculature and shoulder capsule mobility are key. These aspects of treatment will not cure the problem, but will help to reduce secondary issues and give some symptomatic relief
Strength and control – Starting with basic exercises to reeducate load capacity of the rotator cuff and improve the function, control and strength of the scapula (shoulder blade) muscles is key in the initiation of the recovery process.
Load management, functional strength and return to activity planning – As Physiotherapist’s we rarely get people to avoid activities altogether, instead we modify or reduce them to levels the body can manage at that time. A progression in the complexity, load and load tolerance in strength training can be made once pain is under more control and the shoulder is progressing through the thawing stage.
What are your treatment options?
- Painkillers and anti-inflammatory medications can be used to help manage the discomfort you feel in the initial stages of Adhesive Capsulitis. See your GP or pharmacist in relation to this.
- Physiotherapy – key part of shoulder pain management – work on muscle release / massage, education on good posture, improvement of shoulder blade positioning and strengthening of the shoulder muscles as the shoulder thaws.
- Injections – Can benefit through a reduction in inflammation and slight improvement on pain. This is generally most helpful in the very early stages <3 weeks or in those with greatly increased pain levels.
- Surgery – Very rarely is surgery required and the success rate is low to moderate. Surgical management involves either hydrodilation (Filling the joint with fluid), arthroscopic capsular release (Cutting the shoulder capsule) or manipulation under anaesthetic (MUA). The goal of these surgeries is to reduce the effects of capsulitis through releasing the capsule away from the upper arm bone allowing for easier movement, less pain and reduced inflammation.
How can a physio help?
Adhesive Capsulitis is a complex condition which usually resolves on its own. However, its a problem which can lead to secondary issues or while it heals uncover an injury which caused it in the first instance. Adhesive Capsulitis requires management based not on a set of standardised exercises or processes, but an individual tailored management approach. An approach using a comprehensive mix of manual therapy, massage and soft tissue release alongside strength and mobility exercises completed inline with the progressive phases of the condition will give a better outcome. Physiotherapists are well placed to help in the recovery from this issue.
- Guide you on your most appropriate exercises and other helpful treatments.
- Answer questions related to your shoulder pain, and explain in greater detail the contents of this blog where necessary.
- Help you understand why you have Adhesive Capsulitis, what factors have most likely caused your pain and how to modify your activity to improve your pain and recovery.
- The initial stages of rehabilitation / treatment will look at pain reduction and some early mobility work to settle the pain and improve the activity level of the shoulder for comfort. This is done before progressing to foundation strength and flexibility work to provide a base for the shoulder to move more efficiently. This allows a graded return back into more normal activities through the first two phases of Adhesive Capsulitis. Whilst in clinic we will look to provide exercises or manual therapy which may be important to improve pain and flexibility.
- The later phases of rehabilitation and treatment will look to include more advanced and comprehensive strengthening, power, and plyometric work; as well as key continuous management of the rotator cuff and shoulder blade stabilizing muscles which form the foundations of shoulder movement.
As with all advice included in the Activate Physiotherapy blog’s this is not meant to replace assessment and treatment from a trained health professional. Getting a professional opinion can help stop things becoming a persistent problem which further impedes your wellbeing. So, if in doubt get it checked out!
Thanks for reading
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