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FrozenShoulder

Background

Frozenshoulderisalonglastingpainfulconditionthatresultsindecreasedrangeof

motionattheglenohumeral(GH)joint.1,2Theconditionwasfirstdescribedinthelate1800’s

andreferredtoasscapulohumeralperiarthritis.3,4Inthe1930’sitwascalledfrozenshoulder

byCodmanandinthe1940’sNeviaserreferredtotheconditionasadhesivecapsulitis.3,5

Othernamesfortheconditionincludestiffshoulder,thefiftyyearshoulder(inAsian

countries),andcontractureoftheshoulder.4Thevarietyofnamescanbecontributedtothe

factthatfrozenshoulderisstillnotwellunderstood.Asresearchattemptstoexplainthe

etiologyandpathologyoftheconditionthenamesfortheconditionhaveevolved.In2011

themajorityofthemembersoftheAmericanShoulderandElbowSurgeonsagreedwiththe

followingstandarddefinitionforfrozenshoulder:“aconditioncharacterizedbyfunctional

restrictionofbothactiveandpassiveshouldermotionforwhichradiographsofthe

glenohumeraljointareessentiallyunremarkableexceptforthepossiblepresenceof

osteopeniaorcalcifictendonitis.”6p.323

Epidemiology

Frozenshoulderhasaprevalencerateof2-5%inthegeneralpopulation.2,7Women

aremoreaffectedthanmen.Frozenshouldermostcommonlyoccursbetweentheagesof40

and65years2,7,8withthemostcommonagebeinginthemid-fifties.2IndividualswithtypeI

diabeteshavea40%chanceofdevelopingfrozenshoulderwhileapproximately29%of

peoplewithtypeIIdiabeteswilldevelopthecondition.7Otherconditionsthatareassociated

withfrozenshoulderincludethyroiddisorders,Parkinsondisease,autoimmuneconditions,

andheartdisease,7Dupuytrenscontracturesandbreastcancertreatments.9Havingfrozen

shoulderinonearmincreasestheriskofgettingfrozenshoulderintheotherby5-34%.8

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Anatomy

Theglenohumeraljointisaball-and-socketsynovialjointthatissurroundedbythe

GHcapsuleandligaments.Whenthearmisrelaxedattheside,theGHcapsuleistightonthe

superioraspectandloosebothanteriorlyandinferiorly.10Thislaxityallowsforfull

abductionandexternalrotationofthehumerus.TheGHcapsuleisstrengthenedbyboththe

GHligaments(superior,middle,andinferior)andthecoracohumeral(CH)ligament.The

threeGHligamentsarethickenedareasofthatcapsule.ThesuperiorGHLextendsfromthe

superiorglenoidlabrumtotheneckofthehumerusdeeptotheCHligament.10Themiddle

GHLoriginatesonthesuperioranterioraspectofthelabrum,inferiortotheSGHL,and

attachesontheproximalhumerusinferiortotheSGHLattachment.TheinferiorGHLis

madeupofanaxillarypouchthatispositionedbetweenanteriorandposteriorbands.10The

CHligamentoriginatesonthecoracoidprocessandjoinswiththeanterioraspectoftheGH

capsulebeforeinsertingonthelesserandgreatertuberositiesofthehumerus.Becausethe

CHligamentattachestobothtuberosities,itcrossesthebicipitalgrooveandkeepsthelong

headofthebicepstendoninplace.11Thetriangularareabetweenthecoracoidprocess,the

anterioraspectofthesupraspinatustendon,andthesuperioredgeofthesubscapularis

tendonisknownastherotatorinterval.11Therotatorintervalcapsuleisacombinationof

theGHcapsule,theCHligament,andtheSGHL.11(seeFigure1inAppendix)

Pathology

Thecauseandpathologyoffrozenshoulderisstillnotwellunderstood,but

informationhasbeengainedthroughbiopsiesthathavetakenplaceduringsurgical

interventions.Onepossibilityisthatfrozenshoulderbeginsasaninflammatoryresponse

thatisthenfollowedbycapsularfibrosis.2,12Becauseindividualshavepainbeforetheybegin

showingadecreaseinrangeofmotion,itisthoughtthattheinflammatoryprocesshappens

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beforethefibrosis.Histologicalstudieshavefoundbothinflammatorycellsandan

abundanceofproliferatingfibroblasts.12Studieshavealsoidentifiedthegrowthofnew

bloodvesselsandnerveswithintheGHcapsuleandsupportingligamentswhichcanhelp

explainthehighlevelsofpainthatisexperiencedbythosewithfrozenshoulder.8,12The

structuresoftherotatorintervalincludingtheGHcapsule,CHligament,andSGHligament

havebeenfoundtohavesignificantfibrosisandcontractureandbetheprimaryareaof

changeinindividualswithfrozenshoulder.8,12Inadditiontodecreasingthelaxityofthe

rotatorinterval,theoverallGHcapsuleundergoesfibroticchangesthatreducetheoverall

volumeofthejoint.8ThestructuresoftherotatorintervalincludingtheCHligamentresist

externalrotation(ER)whenthearmisattheside;asthehumerusisabducted,thelaxityin

theIGHligamentdisappearsandtheIGHligamentpreventsthehumeralheadfrom

translatingtoofarintheinferiordirection.10Asthecapsulebecomesfibroticand

contracturesform,normalexternalrotationandabductionbecomeslimited.

Classification

Aclearlydefinedclassificationsystemforfrozenshoulderhasnotbeenconsistently

usedthroughouttheliterature.In2011thefollowingclassificationsystemwasproposedby

Zuckermaninanefforttomakeclinicaldiagnosesmoreconsistentandincreasetheabilityto

compareresearchstudies.6Individualswhohavealimitationinbothactiveandpassive

rangeofmotionoftheGHjointwhenx-raysshownothingotherthanpossiblyosteopeniaor

calcifictendonitis,willbediagnosedwitheitherprimaryorsecondaryfrozenshoulder.

Primaryfrozenshoulderisalsoreferredtoasidiopathicandthereisnoknowncauseor

relatedcondition.Iftheetiologyoranassociatedconditioncanbeidentified,thepersonis

classifiedwithsecondaryfrozenshoulder.6Secondaryisdividedfurtherintothreegroups:

systemic,extrinsic,andintrinsic.6,8Secondarysystemicincludesindividualswithdiabetes,

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thyroidconditions,autoimmuneconditionsoranyothersystemicconditionthathasbeen

associatedwithfrozenshoulder.Secondaryextrinsicincludespathologiesthatarenot

directlyrelatedtotheshouldersuchasbutnotlimitedtostroke,heartdisease,distalarm

fracture,andbreastcancertreatment.Secondaryintrinsicfrozenshoulderiscausedbya

pathologywithintheshoulderitself(ex:rotatorcuffinjury,upperarmfracture,damaged

labrum,acromioclavicularinjury,bicepstendinopathy).6,8

Stages

Frozenshoulderistypicallythoughttoprogressthroughthreestages(freezing,

frozen,andthawing),2,5butothersdescribeitashavingfourphases(Table1inAppendix).8,9

Thereisnoclearbeginningandendtoeachphase,butinsteadtheyrepresenttheclinical

andhistologicalprogressionthathasbeenseen.Hereitwillbedescribedasfourstages.

Stage1beginswithagradualonsetofpainattheendrangesofGHmotion,achingpain

duringrest,andmoreintensepainwithmovement.8,9Peopleareoftenunabletosleeponthe

affectedsideandnightpainiscommon.Duringstage1motionisrestrictedbypain,but

whenunderanesthesiafullrangeofmotionispossible.Contracturesarenotpresentatthis

time,butthereisaninflammatorysynovialreaction.9Stage2isalsocalledthe“painful”or

“freezing”stage;theintensityofpainoftenincreasesandmotionbecomesmorelimitedinall

directions.9Fullrangeofmotionisnotpossibleunderanesthesiaduetoaclearreductionin

theaxillarypouch.9Stage3iscommonlycalledthe“frozen”stage.Thepainisoftenless

commonandlesssevere,butstiffnessorlackofmotiondominates.9Duringthistimethereis

adecreaseinthesynovialinflammationandthenumberofbloodvesselsinthearea,buta

continuedincreaseinthecapsularfibrosis.Afulllossoftheaxillarypouchhasbeenfound

whichgoesalongwiththefindingsthatthereisnoimprovementintherangeofmotion

whentheindividualisunderanesthesia.8,9Stage4isreferredtoasthe“thawing”orchronic

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stage.Thereislittle,ifany,pain,butlargerangeofmotionlossesarestillpresent.8,9

Graduallymotionwillimprovealthoughthereisnotspecificconsensusonhowmuchmotion

willreturnorhowlongitwilltake.Frozenshoulderhasbeensaidtoresolvein12to18

months,butlong-termstudiesshowitmaytakeseveralyearsandthatfullresolutionisnota

given.8Asurveyofover200patientsfoundthat59%hada“nearnormalshoulder”52

monthsaftersymptomsbeganaccordingtotheOxfordShoulderScale(OSS),35%had

mild/moderatesymptomsand6%hadseveresymptoms,butatthreeyears56%reported

mild/moderatesymptoms.13Anotherlong-termstudyfound45%ofpatientshadpainor

rangeofmotionrestrictionswhenevaluated40-48monthsafteronset.14Lessthanhalfof

the40%thathadalimitedrangeofmotion,realizedtheirmotionwasrestricted.14This

supportsthatthemajorityofindividualsthatexperiencefrozenshoulderwillhavenormal

functionalmobilitythreetofouryearsafteronset.Althoughtherangeofmotioninmost

directionswassignificantlylessthanthatofcontrolsmatchedforageandsex.14

Diagnostics

Clinicaldiagnosisoffrozenshoulderisbasedonthepatient’shistoryandphysical

exam.2,7,8Theindividualwillpresentwithagradualonsetofpaininaunilateralshoulder

thatoftenoccursatnightandissevereenoughtopreventlyingontheinvolvedsideor

wakesthemduringsleep.Theendrangesofmotionarealsopainful.8Adefinitionthathas

beenusedinmanystudiesis“ROMlossgreaterthan25%inatleasttwoplanesandpassive

externalrotationlossthatisgreaterthan50%oftheuninvolvedshoulderorlessthan30

degreesofexternalrotation.”8Reductioninexternalrotation,abduction,forwardflexion,

andinternalrotationarethemostcommon.7Nospecificcapsularpatternhasbeen

identified.ExternalrotationismorelimitedwhentheGHjointisat0degreesofabduction

ascomparedto90degreesofabductionwhileinternalrotationistheopposite(more

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restrictedat90degreesabduction).15Rangeofmotionrestrictionsshouldhavebeenpresent

foratleastonemonth,8butseveralstudieshaveusedaminimumthreemonthdurationas

partofthediagnosticcriteria.15Functionalmobilitywillbelimitedduetothepainand

decreasedrangeofmotion;placingahandinabackpocketandreachingoverheadorbehind

theneckcanbedifficultorimpossibletoperform.2,8

Otherpathologiesmustberuledout,especiallyduringstage1ofthefrozenshoulder

whenthereisnotyetapassiverangeofmotionrestriction.Theisometricstrengthofthe

rotatorcuffistypicallynormal,8,16althoughpainrelatedweaknessmaybepresentwhen

neartheendrangesofmotion.Specialteststhatrequirethepatienttoactivelyorpassively

movetoendrangescanproducefalsepositiveresults.Amainsignoffrozenshoulderwillbe

thefirmor“tethered”endfeelofthepassiverangeofmotion.16

Imagingstudiescanbeusedtoruleoutunderlyingpathologiessuchasosteoarthritis

androtatorcufftendinopathies,butarenotthereferencestandardwhendiagnosingfrozen

shoulder.Radiographsshouldbenormalexceptforpossibleosteopeniaorcalcific

tendonitis.6,8MRI’sarenotnecessary,butcanhelpwithdifferentialdiagnosis.MRIfindings

consistentwithfrozenshoulderincludeCHligamentandrotatorintervalthickening,2,3,8

reducedaxillarypouch,8andsynovitis-likeabnormalitiesaroundthelongheadofthebiceps

tendon.3

Interventions

Frozenshoulderisconsideredaself-limitingconditionwithavarietyofinterventions

thatcanbeutilized.Researchhasnotfoundadefinitivetreatmentapproach,butmultiple

treatmentshaveshownbenefits.Becauseindividualsrecoveratdifferentratesandsome

havesymptomsthatarestillpresentlong-term,8,13,14patienteducationisvital.Information

regardingthenaturalprogressionofthecondition,8,17theimportanceofdoingadailyhome

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exerciseprogram,8,17andtheneedtomatchtheintensityofexercisestotheirritability

level17shouldbeprovided.Commonconservativeinterventionsincludecorticosteroid

injections,intra-articulardilation(distension)andphysicaltherapytreatmentssuchas

modalities,jointmobilizations,andstretching,andahomeexerciseprogram.More

aggressiveapproachesincludemanipulationoftheGHjointunderanesthesiaand

arthroscopicsurgicalrelease.

Oralmedications,acetaminophenandnon-steroidalanti-inflammatories,aretypically

usedearlyforpainrelief,butthereislittleresearchtosupporttheiruse.Asystematic

reviewforNSAIDsrelatedtomultipletypesofshoulderconditionsfoundastatistically

significantimprovementascomparedtoplacebo,butthestudiesusedhadsmallsample

sizesandpoorquality.18

Asystematicreview(SR)evaluatingtheeffectivenessofGHcorticosteroidinjections

foundtheinjectionsprovideshorttermreliefforfrozenshoulder.7Thesebenefitsareseen

duringstage1andstage2(freezing).19Statisticallyandclinicallymeaningfulimprovements

forpainandfunctionwereobservedat6-weeks,butnotlonger.Corticosteroidinjections

outcomesat12weeksweresimilartootherinterventionsandplacebo.7Injectionsresulted

inagreaterimprovementinoutcomemeasuresascomparedtophysicaltherapyaloneata

short-term6-weekfollowup.7Intra-articularinjectionsresultedingreaterimprovementsin

painandROMascomparedtoextra-articularinjections.7Corticosteroidinjectionsworkby

decreasingtheinflammatoryresponseanddecreasingpain,8soaccurateplacementofthe

medicationcouldbeimportantforthegreatestbenefitstoberealized.Physiciansaremore

accuratewithinjectionplacementwhenusingimage-guidedinjectiontechniquesas

comparedtoanatomicallandmarkinjectiontechniques(92-100%accuracyvs.26-79%

accuracy).7TheSRdidnotfindasignificantdifferencebetweentheinjectiontechniques,but

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image-guidedplacementmayresultinbetteroutcomesaccordingtosomeindividual

studies.2

Intra-articulardilationordistensioninvolvesinjectingtheGHjointcapsulewith

salineorasaline/corticosteroidcombination.Thesalineisinjectedintothecapsuleunder

pressure,inanefforttoexpandthecapsulesincetheoverallvolumeistypicallyreduced

withfrozenshoulder.8Asystematicreviewfoundshort-termimprovementsinpain,rangeof

motion,andoverallshoulderfunctionwhendistensionwasdonewithacombinationof

salineandcorticosteroid,butdistentionwithcorticosteroidshasnotbeenshowntobe

betterthanonlyacorticosteroidinjection.2

Modalitiescanimprovesymptomsoffrozenshoulder,buttheuseofmodalitieswith

otherinterventionsandthelowqualityevidencemakesitdifficulttostateifasingle

modalityiseffectivewhenusedaloneorbetterthananother.8,20AsystematicreviewbyPage

etal.wasonlyabletoidentifythatlow-levellasertherapy(LLLT)maybebetterthan

placeboaftersixdaysoftreatmentandLLLTplusexercisemaybebetterthanexercisealone

atfourweeksforpaincontrol.20AsystematicreviewbyJainfoundstrongevidencethatLLLT

improvespain,moderateevidencethatitimprovesfunction,andnoevidencethatitaffects

ROM.19Theadditionofdeepheat,shortwavediathermy,tostretchingmadesignificantgains

inROMascomparedtosuperficialheat/stretchingorstretchingalone.Thedeepheatalso

providedbenefitsinpainandfunction.19Nobenefitsinpain,ROM,orfunctionwerefound

withultrasoundinthesystematicreview,19butultrasoundwasfoundtoincreaseonlyROM

immediatelyposttreatmentandata3-monthfollow-upinstudybyDogruetal.8Thereisnot

strongevidencefortheuseofothermodalitiessuchasiceorelectricalstimulation,but

tryingtheseinterventionsmaybeappropriateforindividualswithhighlevelsofpain.

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Physicaltherapyexerciseandmobilizationsarehighlyrecommendedduringstage3

(frozen)andstage4(thawing)toassistwithpainreduction,regainingROM,andimproving

function.19Thephysicaltherapyinterventionshouldbebasedontheirritabilitylevelofthe

patient;astheirritability/paindecreasestheintensityoftheinterventioncanincreaseto

focusonregainingROM(Table2inAppendix).17Patientswithhighirritabilitywillperform

easy,short-durationROMexercisesforpainreductionandreceptorinput;ROMexercises

shouldbedone2-3timesadayforafewsecondsinalmostapain-freerange.17Pushinginto

thepainatthispointhasnotbeenfoundtobebeneficial.8,17Theintensityandholdtimeof

thestretchshouldincreaseasthepaindecreasesaswellasthefrequencyoftimes

performedduringtheday.AsystematicreviewonmanualtherapyandexercisebyPageet

al.determinedthatmanualtherapyandexercisemaynotdoaswellascorticosteroid

injectionsforshort-termresults.21AsystematicreviewbyFavejeeetal.identifiedthe

following:highgrademobilizationsimprovedGHmobilityanddecreaseddisabilitymore

thanlowgrademobilizations,posteriormobilizationsincreasedexternalrotationmorethan

mobilizationsintheanteriordirection,end-rangemobilizationsandmobilizationswith

movementweremorebeneficialthanmid-rangemobilizations,andmobilizationswith

movementwerebetterthanend-rangemobilizationsforscapulohumeralrhythm.22Overall,

physicaltherapyexerciseandmobilizationscanimproverangeofmotion.Allpatients

shouldperformaHEPthatconsistsofpassiveROMexercisesattheGHjoint:flexion,

extension,internalrotation,externalrotation,horizontaladduction,andabduction(Figure2

inAppendix).

Ifimprovementsdonotoccurwithconservativeinterventionsaftersixmonths17or

afteroneyear2referraltoaphysicianforconsiderationofamoreinvasiveprocedurecould

bethenextstep.Manipulationunderanesthesia(MUA)adequatelyincreasesthepatient’s

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ROM,butdoesnotallowthephysiciantheabilitytoisolatespecifictissues.2,17MUAinvolves

stabilizingthescapulawhilethehumerusisforcefullymovedpastend-rangeto“tear”the

capsule.Multiplestudieshavehadpositiveoutcomesin75-100%ofthesubjectsundergoing

MUA,17butthereistheriskoffracture,nerveinjury,muscleinjuries,andlabraltears.23

Arthroscopiccapsularreleaseallowsthephysiciantoselectspecificpartsofthecapsuleto

release.Arthroscopicreleasehasresultedinimprovedoutcomes:lesspain,improvedROM,

andbetterfunction.AsystematicreviewbyGrantetal.foundverylittledifferencesbetween

theresultsofMUAandarthroscopiccapsularrelease.23ThisSRfoundcapsularrelease

resultedinmoreabductionandexternalrotation,6degreesand8degreesrespectively,as

wellasaslightlyhigher,butnon-significantdifferenceinadisabilityoutcomemeasure.

SimilarcomplicationrateswerealsofoundbetweencapsularreleaseandMUA,0.5%and

0.4%respectively.23Manipulationisoftendoneimmediatelyfollowingthearthroscopic

capsularreleasetoregainfullmotion.ArthroscopiccapsularreleasecombinewithMUA

demonstratedROMimprovementsof~70degreesinflexion,~30degreesinexternal

rotation,andinternalrotationgainsmeasuredbyreachingtoL1insteadofL5inastudyof

50patientsthathadfailedoversixmonthsofconservativetreatment.24Patientsthathave

diabeteshaveoutcomesthataresignificantlybetterfollowingcapsularrelease,buttheir

improvementsaresignificantlylowerthanthosewithoutdiabetesandoftenhavelong-

lastinglimitations.25

OutcomeMeasures

TheDisabilityoftheArm,Shoulder,andHandScale(DASH)andtheShoulderPain

andDisabilityIndex(SPADI)aretwoofthemostcommonlystudiedshoulderoutcome

measures.8,26Becauseneitherhavebeenfoundtohavefloororceilingeffectsandbothhave

goodresponsiveness,theyarerecommendedintheoutpatientsetting.26TheSPADIismore

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responsivethantheDASHforpatientswithfrozenshoulder.8TheDASHisaself-report

questionnairewith30itemsthatarescoredonaonetofivescale.Therawscoreis

convertedtoa0-100scalewith0meaningnodisabilityand100fullydisabled.27The

minimaldetectablechange(MCD)isbetween6.6–12.2points(average10)with10.2points

asthechangeneededtobeclinicallymeaningful.8TheQuickDASHisashortened11-item

questionnairethatalsomeasuresphysicalfunctioninpatientswithanupperextremity

condition.TheQuickDASHhasbeenfoundtobevalid,reliable,andresponsive,butthe

originalDASHprovidesamorecomprehensivepicture.28TheSPADIisaself-report

questionnairethatassessespainanddisability.Fivequestionsareaboutpainand8

questionsaddressdisabilityforatotalof13totalitems.8TheMDCfortheSPADIis18points

whileachangebetween8and13isclinicallymeaningful.29,30SincepainandlimitedROMare

thetwoprimarycomplaintsoffrozenshoulder,bothoftheseshouldbeobjectively

measured,inadditionto,usinganoutcomemeasurefordisability.Thevisualanalogscale

canbeusedforoverallpain,butcanalsobeusedinconnectionwithspecificactivitiesthat

aredifficultsuchaspainduringsleep,reachingbehindtheback,orwhengettingdressed.

BothactiveandpassiveROMcanbemeasuredwithagoniometerinthefollowingplanesof

motion:flexion,abduction,internalandexternalrotationat90degreesofabduction(45

degreesif90isnotpossible),andexternalrotationat0degreesabduction.8

Conclusion

Frozenshoulderisconsideredaself-limitingconditionthatcausesdisabilitythrough

highlevelsofpainanddecreasedROM,buttheunderlyingcauseisnotwellunderstood.

2,8,9,12Someresearchersbelieffrozenshoulderbeginsasaninflammatoryprocesswhich

thentransitionstoafibroticconditionresultinginatightenedGHjointcapsulewithreduced

ROM.2,12,17TheCHligament,rotatorinterval,andaxillarypoucharethestructuresmost

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commonlyaffected3,8,11resultinginlossesofexternalrotation,abduction,andflexion.The

conditionprogressesthroughfourstages:1)earlypainwithfullROM,2)“freezing”or

“painful”,highlevelspain,limitedmotion,3)“frozen”,lesspain,increasedROMrestrictions,

4)“thawing”,littletonopain,largeROMdeficits,ROMbeginstoimprove.8,9Resolutionoften

occurswithinonetofouryears,butcompleteresolutionmayneveroccur.13,14Conservative

treatmentshouldbeattemptedforsixmonthsto1yearbeforesurgicalinterventionsare

explored.Patienteducationabouttheprogressionoftheconditionandtheimportanceofa

dailyHEPshouldbeprovided.Thereisnotevidencetosupportaspecificconservative

interventionasthebest,2,7,17,19,20,22butthepainirritabilitylevelofthepatientandthestage

oftheprogressionshouldbeconsideredwhendecidingatreatmentapproach.2,17Intra-

articularcorticosteroidinjectionsareeffectiveatreducingshort-termpainandshouldbe

usedduringtheearlystages.2,7,8Physicaltherapy(exercise,ROM,mobilizations,modalities)

isimportantforimprovingROMespeciallyduringthe“frozen”and“thawing”stages.9,17,19,22

MoreinvasivetreatmentoptionssuchasMUAandarthroscopiccapsularreleaseare

availableforpatientsthathavepersistentdisabilitywhenconservativemethodsfail.2,8,17,23

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shoulderinpatientswithandwithoutdiabetes.BoneJointJ.2014;96-B(10):1355-

1358.doi:10.1302/0301-620X.96B10.34476.

26. BotSDM,TerweeCB,vanderWindtDAWM,BouterLM,DekkerJ,deVetHCW.

Clinimetricevaluationofshoulderdisabilityquestionnaires:asystematicreviewofthe

literature.AnnRheumDis.2004;63(4):335-341.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1754942&tool=pmcentr

ez&rendertype=abstract.AccessedOctober27,2015.

27. SmileyJ,ToddA,CalabreseF,FaganA,GalvinP.RehabMeasures:Disabilitiesfothe

Arm,Shoulder,andHandQuestionnaire.2013.

28. TheQuickDASH.DASHOutcomeMeas.

29. RoyJ-S,MacDermidJC,WoodhouseLJ.Measuringshoulderfunction:asystematic

reviewoffourquestionnaires.ArthritisRheum.2009;61(5):623-632.

doi:10.1002/art.24396.

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30. RehabMeasures:ShoulderPainandDisabilityIndex.2015.

http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=1207.

AccessedNovember30,2015.

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Appendix

Figure1–RotatorIntervalAnatomy11–Petchprapaetal.2010

Table1–FourStagesAdhesiveCapsulitis9–Neviaser2010p.2347

568 AJR:195, September 2010

Petchprapa et al.

in only four of 63 (6%) shoulder dissections by Neer et al. [1].

The SGHL is a fold–focal thickening of the glenohumeral joint capsule (Fig. 4). It is variable in origin (supraglenoid tubercle, su-perior labrum, long head biceps tendon, mid-dle glenohumeral ligament, or some combina-tion) and may be absent in 3% of patients at arthroscopy [2]. The SGHL is anterior to and maintains a close relationship with the biceps tendon along its course. Before it inserts into a small depression above the lesser tuberosity (known as the fovea capitis of the humerus), it contributes to the biceps reflection pulley.

The long head of the biceps tendon may arise from the posterosuperior labrum, supraglenoid tubercle, or a combination of both [3]. The

tendon takes an oblique intraarticular course through the rotator interval and must make a 30° to 45° turn along the anterior surface of the humeral head before it exits the joint be-tween the lesser and greater tuberosities in the intertubercular groove. Anomalies of the bi-ceps brachii muscle are common, with 9–23% showing supernumerary heads [4]. More rare variants, particularly of the intraarticular por-tion of the long head of the biceps tendon, also have been reported in the literature [5].

The CHL and SGHL form a slinglike band surrounding the long head of the biceps tendon proximal to the bicipital groove (Fig. 5). This biceps reflection pulley plays an important role in the stability of the intraarticular biceps ten-don. When the arm is abducted and externally rotated, the pulley limits medial subluxation of the biceps tendon. Medially, the superior gle-nohumeral ligament lies anterior to the biceps tendon. Further laterally, the ligament folds into a cup-shaped structure that cradles the biceps tendon. At the opening of the bicipital groove, SGHL fibers are joined by medial fibers of the CHL to form the biceps reflection pulley [6]. The subscapularis and supraspinatus tendon insertions along the lesser and greater tuberos-ities, respectively, blend with those of the CHL and are thus intimately associated with the bi-ceps pulley [7, 8]. Injuries to any of these com-ponents of the sling are referred to as “pulley lesions” [9, 10].

ImagingImaging the components of the rotator in-

terval poses several challenges. The small

size of the structures requires high spa-tial resolution; this is optimized by the use of strong gradients, surface coils, and high-field-strength MR scanners that maximize the signal-to-noise ratio. Even after imag-ing parameters are optimized, evaluating the structures of the rotator interval can be difficult. Most often, the SGHL, CHL, and rotator interval capsule appear as interme-diate-weighted soft tissue filling the rotator interval and surrounding the biceps tendon. These normally coapted structures also can appear spuriously thickened when the shoul-der is internally rotated; in this position, the rotator interval structures are not taut. In-traarticular fluid, either a joint effusion or in-traarticular contrast material, separates the folds of tissue in this region and allows better structure delineation. It is for this reason that MR arthrography is recommended when ab-normality of the rotator interval is suspected [11], and this is our preference. Nonarthro-graphic images, however, do allow evalua-tion of the extraarticular portion of the CHL and the subcoracoid fat that surrounds it.

At our institution, MR arthrography is done after 10–12 mL of dilute (1:200 solu-tion) gadopentetate dimeglumine (Mag-nevist, Bayer HealthCare Pharmaceuticals) is injected into the joint and follows standard arthrography protocol: axial fat-saturated T1-weighted (TR/TE, 514/8.6), coronal oblique fat-saturated T1-weighted (754/8.6), sagittal oblique T1-weighted (450/9.4), coronal oblique fat-saturated T2-weighted (5,880/79), and abduction and external rotation

A

Fig. 1—Rotator interval.A–C, Illustrations in coronal (A) and sagittal (B) planes and corresponding sagittal MR proton density–weighted arthrogram (C) show boundaries of rotator interval, which are defined by coracoid process (COR) at its base, superiorly by anterior margin of supraspinatus tendon (SST) and inferiorly by superior margin of subscapularis tendon (SSC). Contents of rotator interval include long head of biceps tendon (BT), coracohumeral ligament (CHL), superior glenohumeral ligament (SGHL), and rotator interval capsule. Rotator interval capsule (RIC) is anterosuperior aspect of glenohumeral joint capsule, which merges with CHL and SGHL insertions medial and lateral to bicipital groove. CHL arises from base of coracoid process, traverses through subcoracoid fat, and inserts on anterior humerus. IST = infraspinatus tendon.

CB

Fig. 2—Photograph of anterior view of cadaver dissection shows stout coracohumeral ligament (CHL); it suspends shoulder joint from coracoid process. CHL arises from lateral base of coracoid process (CP) and broadly inserts on lesser and greater tuberosities where it becomes confluent with subscapularis tendon (black star), supraspinatus tendon (white star), and rotator interval capsule (asterisk).

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used to describe the idiopathic process of global capsularinflammation and fibrosis occurring in the absence of otherlesions. Secondary adhesive capsulitis has been used todescribe a constellation of conditions resulting in a stiffshoulder.41 Some of these conditions demonstrate isolatedareas of capsular contracture that are indistinguishablefrom idiopathic adhesive capsulitis but occur concurrentlywith other known injuries or diseases. Others have anextra-articular cause of shoulder stiffness without involve-ment of the joint capsule. Calcific tendinitis, rotator cuffinjury, biceps tendinitis, as well as glenohumeral or acro-mioclavicular arthritis, all can cause shoulder stiffness inthe absence of capsular limitation of motion. Distinguish-ing between primary or idiopathic disease and pain dueto other causes can be difficult and there is frequent over-lap. Yoo et al78 reported that 62% of patients with stage 2idiopathic adhesive capsulitis were found to have supraspi-natus lesions, most commonly partial-thickness tears, afterundergoing magnetic resonance imaging (MRI).

Subtle clues in the history and physical examinationallow discrimination of primary adhesive capsulitis fromthese other conditions. Treatment of so-called secondaryadhesive capsulitis should be directed toward the associatedcondition causing immobilization of the shoulder, and

outcomes differ based on that condition.30,50 Only the treat-ment of primary adhesive capsulitis will be discussed here.

Adhesive capsulitis progresses through 4 stagesdescribed by Neviaser and Neviaser49 based on the correla-tion of physical examination and arthroscopic examinationof affected joints. Hannafin et al28 demonstrated the histo-pathological progression of disease in capsular biopsiesfrom patients with Neviaser stages 1 to 3. Recognition ofthese stages is essential to applying appropriate treat-ment, communicating prognosis, and establishing theexpectations of both patient and physician (Table 1). Thearthroscopic and histopathological appearances of theshoulder capsule in the various stages of disease are dis-cussed below. These are not required to identify the stagesof disease. Diagnosis and staging of adhesive capsulitis aredetermined clinically based on symptoms and physicalexamination. Intra-articular anesthetic injection can beused to discriminate between the first 2 stages.

Stage 1 is characterized by a gradual onset of pain typ-ically referred to the deltoid insertion. It is usually achy atrest and sharper with movement. Pain at night is common,and patients frequently report an inability to sleep on theaffected side. Duration of symptoms is generally lessthan 3 months. Capsular pain on deep palpation or passive

TABLE 1Stages of Adhesive Capsulitis

Symptoms Signs Arthroscopic Appearance Biopsy

Stage 1

Pain referred todeltoid insertionPain at night

Capsular pain ondeep palpation

Empty end feel atextremes of motion

Full motion underanesthesia

Fibrinous synovialinflammatory reaction

No adhesions or capsularcontracture

Rare inflammatorycell infiltrate

Hypervascular,hypertrophic synovitis

Normal capsular tissue

Stage 2

Severe night painStiffness

Motion restricted inforward flexion,abduction, internal andexternal rotation

Some motion lossunder anesthesia

Christmas tree synovitisSome loss of axillary fold

Hypertrophic,hypervascular synovitis

Perivascular,subsynovial capsularscar

Stage 3

Profound stiffnessPain only at the end

range of motion

Significant loss of motionTethering at ends of motionNo improvement

under anesthesia

Complete loss ofaxillary fold

Minimal synovitis

Hypercellular,collagenous tissue witha thin synovial layer

Similar features toother fibrosingconditions

Stage 4

Profound stiffnessPain minimal

Significant motion lossGradual improvement

in motion

Fully mature adhesionsIdentification of intra-

articular structures difficult

Not reported

Vol. 38, No. 11, 2010 Adhesive Capsulitis 2347

at University of North Carolina at Chapel Hill on November 28, 2015ajs.sagepub.comDownloaded from

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Table2–TreatmentStrategiesBasedonIrritabilityLevel17–Kelleyetal.p.140

Figure2–PassiveROMExercisesforHEP–Kelleyetal.p.140

140 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

[ CLINICAL COMMENTARY ]in less pain and improved motion in pa-tients with frozen shoulder.99

The basic strategy in treating structuralstiffness is to apply appropriate tissuestress.74 It is helpful to think of the totalamount of stress being applied as the“dosage,” in much the same way that dos-age applies to medication. The primaryfactors that guide this process are painand ROM. Adjusting the dose of tissuestress results in the desired therapeuticchange (increased motion without in-creased pain). Three factors should beconsidered when calculating the dose, ortotal amount of stress delivered, to a tis-sue: intensity, frequency, and duration.The total end range time (TERT)34,66 is thetotal amount of time the joint is held ator near end-range position. TERT is cal-culated by multiplying the frequency andduration of the time spent at end rangedaily, and is a useful way of measuring thedose of tissue stress.34,66 Intensity remainsan important factor in tensile stress dosebut is typically limited by pain. Tradition-al ROM exercises are considered lowerforms of tensile stress, while the highesttensile stress doses are achieved by low-load prolonged stretching (LLPS), be-cause TERT is maximized. Therefore, thegoal with each patient is to determine thetherapeutic level of tensile stress.

Applying the correct tensile-stressdose is based upon the patient’s irritabil-ity classification ( ). In patients withhigh irritability, low-intensity and short-duration ROM exercises are performedto simply alter the joint receptors’ input,reduce pain, decrease muscle guarding,and increase motion.126

show commonly performed exercises forpatients with high irritability. Stretchesmay be held from 1 to 5 seconds at therelatively pain-free range, 2 to 3 times aday. A pulley may be used, depending onthe patient’s ability to tolerate the exer-cise. These exercises primarily influencedifferent regions of the synovial/CLCand have been used in supervised physi-cal therapy programs and an HEP in

(A) Forward flexion, (B) external rotation,(C) extension.

(A) Internal rotation, (B) horizontaladduction, (C) pulley for elevation.

Treatment StrategiesBased on Irritability Level

Modalities Heat/ice/electricalstimulation

Heat/ice/electricalstimulation

...

Activity modification Yes Yes ...

ROM/stretch Short-duration (1-5 s), pain-free, passive AAROM

Short-duration (5-15 s),passive, AAROM toAROM

End range/overpressure,increased-duration,cyclic loading

Manual techniques Low-grade mobilization Low- to high-grademobilization

High-grade mobilization/sustained hold

Strengthen ... ... Low- to high-resistance endranges

Functional activities ... Basic High demand

Patient education

Other Intra-articular steroidinjection

... ...

Abbreviations: AAROM, active assisted range of motion; AROM, active range of motion.

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140 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

[ CLINICAL COMMENTARY ]in less pain and improved motion in pa-tients with frozen shoulder.99

The basic strategy in treating structuralstiffness is to apply appropriate tissuestress.74 It is helpful to think of the totalamount of stress being applied as the“dosage,” in much the same way that dos-age applies to medication. The primaryfactors that guide this process are painand ROM. Adjusting the dose of tissuestress results in the desired therapeuticchange (increased motion without in-creased pain). Three factors should beconsidered when calculating the dose, ortotal amount of stress delivered, to a tis-sue: intensity, frequency, and duration.The total end range time (TERT)34,66 is thetotal amount of time the joint is held ator near end-range position. TERT is cal-culated by multiplying the frequency andduration of the time spent at end rangedaily, and is a useful way of measuring thedose of tissue stress.34,66 Intensity remainsan important factor in tensile stress dosebut is typically limited by pain. Tradition-al ROM exercises are considered lowerforms of tensile stress, while the highesttensile stress doses are achieved by low-load prolonged stretching (LLPS), be-cause TERT is maximized. Therefore, thegoal with each patient is to determine thetherapeutic level of tensile stress.

Applying the correct tensile-stressdose is based upon the patient’s irritabil-ity classification ( ). In patients withhigh irritability, low-intensity and short-duration ROM exercises are performedto simply alter the joint receptors’ input,reduce pain, decrease muscle guarding,and increase motion.126

show commonly performed exercises forpatients with high irritability. Stretchesmay be held from 1 to 5 seconds at therelatively pain-free range, 2 to 3 times aday. A pulley may be used, depending onthe patient’s ability to tolerate the exer-cise. These exercises primarily influencedifferent regions of the synovial/CLCand have been used in supervised physi-cal therapy programs and an HEP in

(A) Forward flexion, (B) external rotation,(C) extension.

(A) Internal rotation, (B) horizontaladduction, (C) pulley for elevation.

Treatment StrategiesBased on Irritability Level

Modalities Heat/ice/electricalstimulation

Heat/ice/electricalstimulation

...

Activity modification Yes Yes ...

ROM/stretch Short-duration (1-5 s), pain-free, passive AAROM

Short-duration (5-15 s),passive, AAROM toAROM

End range/overpressure,increased-duration,cyclic loading

Manual techniques Low-grade mobilization Low- to high-grademobilization

High-grade mobilization/sustained hold

Strengthen ... ... Low- to high-resistance endranges

Functional activities ... Basic High demand

Patient education

Other Intra-articular steroidinjection

... ...

Abbreviations: AAROM, active assisted range of motion; AROM, active range of motion.

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