January 11, 2017

Adhesive Capsulitis: A Race Against Natural History

Author: Maggie Henjum


Remarkable findings in this week’s literature was the continued discussion of external rotation loss in AC. Overall, patients with AC were noted to have 50% less external rotation compared to contralateral side.2 Also important exam findings may be changes of rotation at various degrees of abduction. It is speculated that if there was a greater loss of external rotation at 45° versus 90° of abduction this may indicate subscapularis restriction or involvement.2 As external rotation limitations does follow capsular pattern of the shoulder, I have seen this to be somewhat controversial in literature to demonstrate that idiopathic shoulders commonly do not follow capsular patterns.4 Thus, this maybe not to be used as a diagnostic tool – more a notable finding with relative understanding that anecdotally I still do see standard loss of ER > abduction > IR in patients with AC.

Approximately 10% of patients do not respond to the variety of nonoperative treatments.3 Consequently, the remaining 90% fall into a three way competition between physical therapy, injection and natural history.

Demographically, I commonly see “hydroplasties” (or intra-articular distension injections) for management of AC. Literature for this procedure is limited – especially when in comparison to a control group. One study by Halverson et. al, performed 21 in-office hydroplasties with 94% of patients improving immediately in PROM, and 53% improved in comfort and function.5 Again, a local study in 2003 revealed similar improvements immediately and long term outcomes of only 3% of patients having continued discomfort at night.6 Both pieces of literature show promising improvement, but both are low level evidence. As stated in a review by Kelly et. al, at a 2 year follow up there was no difference between articular steroid injection with distention over manipulation under anesthesia.2 Again, not demonstrating any comparison to less invasive treatments – but may be useful. Anecdotally, I do see positive outcomes in this procedure in patients with acute, and irritable symptoms but more research will be needed for any substantial decision.

Is there a better option? A technique that I have not seen locally, was originally described idea by Roubal et al and Placzek et al. where they described a technique administering a regional interscalene brachial plexus anesthetic block and then following up with daily PT to mobilize the posterior and inferior capsule.9,10 Taken one step further, Boyles et al. with a case report of four individuals they found significant reduction in SPADI scores and improvement in ROM after three weeks of therapy.11Interestingly enough, patients used were ones who have failed conservative rehab prior to this technique. Reasoning behind GH mobilizations is flawlessly discussed in Vermeulen et. al study as hopeful benefits include the following: (1) neurophysiologic effect on peripheral mechanoreceptors, and inhibition of nocireceptors (2) biomechanical effect to improve tissue quality (breaking up adhesions and re-aligning collagen) and (3) increasing synovial fluid turnover.8 In patient language, it helps get you moving.8Hopefully this block would reduce sensory input and decrease guarding throughout the mobilization process allowing the therapist to obtain greater outcomes. This area does have some promising trends associated with it, although as most areas within adhesive capsulitis, more time will tell.

Consideration of Codman’s original comment that AC is a challenging condition to treat does still seem to be the case as duration of condition continues to range 1-2 years. Although possibly due to respect for our profession and fear of the challenging conversation to have with patients to sell the wait and see method, I hope to see continued general trend of this conditions duration decreasing with management administered in either injection form, or physical therapy interventions. 


Original post: November 1, 2013



1) Codman EA. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or About the Subacromial Bursa. Boston, MA: T Todd Company; 1934.

2) Kelley, M. J., Shaffer, D. P. T. M. A., Kuhn, M. J. E., Michener, L. A., Davenport, T., Fearon, D. P. T. H., … Macdermid, J. (2013). Shoulder Pain and Mobility Deficits : Adhesive Capsulitis Clinical Practice Guidelines Linked to the International Classification of Functioning , Disability , and Health From the Orthopaedic Section. doi:10.2519/jospt.2013.0302

3) Neviaser, A. S., & Hannafin, J. a. (2010). Adhesive capsulitis: a review of current treatment. The American journal of sports medicine, 38(11), 2346–56. doi:10.1177/0363546509348048

4) Runquist PJ, Ludewig PM. Patterns of motion loss in subjects with idiopathic loss of shoulder range of motion. Clinical Biomechanics. 2004. 19; 810-818.

5) Halverson L, Maas R. Shoulder joint capsule distension (hydroplasty): a case series of patients with “frozen shoulders” treated in a primary care office. Journal Of Fam Practice. 2003; 51: 61-3.

6) Callinan N, McPherson S, Cleaveland S, Voss DG, Rainville D, Tokar N. Effectiveness of hydroplasty and therapeutic exercise for treatment of frozen shoulder. J Hand Therapy. 2003;16:219-224.

7) Oh JH, Oh CH, Choi JA, Kim SH, Kim JH, Yoon JP. Comparison of glenohumeral and subacromial steroid injection in primary frozen shoulder: a prospective, randomized short-term comparison study. J Shoulder Elbow Surg. 2011;20:1034-1040. http://dx.doi.org/10.1016/j. jse.2011.04.0294

8) Vermeulen HM, Rozing PM, Obermann WR, Cessie SL, Thea PM, Vlieland V. Grade Mobilization Techniques in the Management of Adhesive Capsulitis of the Shoulder : Randomized Controlled Trial. Physical Therapy. 86(3), 355–368.

9) Placzek JD, Roubal PJ, Freeman DC, Kulig K, Nasser S, Pagett BT. Long-term effectiveness of translational manipulation for adhesive capsulitis. Clinical Orthopedic Relat Res. 1998; 356: 181-191.

10) Roubal, P., Dobritt, D., & Placzek, J. (1996). Glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis. Journal of Orthopaedic and Sports …, 13–26. Retrieved fromhttp://www.udel.edu/PT/clinic/journalclub/old/sojournalclub/96_97/sep96/roubal.pdf

11) Boyles, R. E., Flynn, T. W., & Whitman, J. M. (2005). Manipulation following regional interscalene anesthetic block for shoulder adhesive capsulitis: a case series. Manual therapy, 10(2), 164–71. doi:10.1016/j.math.2004.08.002