Adhesive Capsulitis: How can we make this Dx of inclusion, rather than exclusion?

Adhesive capsulitis has historically been a diagnosis of exclusion, especially at the earliest stages where ROM limitations aren’t as evident and not main complaint.

-This is due to unclear etiology and varying degrees & time course of the disease process.

-It is also made more difficult due to the number of intrinsic/extrinsic factors and primary and secondary classifications.

Most of these patients arrive into your treatment room with similiar complaints consistent with RTC pathology, arthritis, labral injury, etc. that make the differential diagnosis that much harder.

We typically know the signs/symptoms of the latter to aid in a formal diagnosis but applying specific manefistations to stage 1 and particularly stage 2 of adhesive capsulitis is still fairly unknown and difficult.

Catching the freezing stage prior to the frozen stage of adhesive capsulitis can mean a world of difference in treatment and subsequently overall quality of life. Read on for 4 examination procedures that I and           other EBP sources will help in identifying this pathology.

Kelley et al in Feb 2009 JOSPT summarized adhesive capsulitis into classification, etiology/pathology, examination and treatment approaches to aid in a rehablitation guide.  It is a great review and you can find it here.  I really found it helpful to differentiate the stages of adhesive capsulitis and is shown below:

Loss of ER  ROM

To me, the stage that most closely resembles other pathologies, especially of a recent tear of the RTC, is the freezing stage (stage 2), .  However, agreeing with above chart; chronic pain with all active and passive motion is key difference.

-RTC pathology will typically not have pain with passive ROM and will have more pain into internal rotation.

-In freezing stage, there will be limitations in all planes; but especially of passive ER (50% or greater than 30 degree loss) as shown below:

External Rotation Test

This can also be tested through the external rotation test.  Wolf et al showed that a positive ER test should be considered positive for adhesive capsulitis in absence of glenohumeral arthritis and trauma.

The test is performed with the patient’s shoulder in adduction, elbow at 90 degrees of flexion.

-The examiner passively externally rotates the forearm keeping the upper arm by the patient’s side.

-It is considered positive if pain is produced with gentle ER to the limit.  This parallels the above notion with more pain into external rotation.

The authors did not differentiate the stage of adhesive capsulitis with this manuever, but it can be of clinical use as a EBP “diagnostic tool”.

Internal Rotation Strength Deficit

Freezing shoulder will usually show more deficits in internal rotation strength and even pain.  To me, this is highly diagnostic as most other pathologies (predominantly RTC), will have pain with break testing of the external rotators.

-Using a hand-held dynanometer can be very helpful in determining degree of difference for more objectivity.

High Resting Pain Level

I also find that freezing shoulder patients are in the high irritability classification system as listed below. To me, the main findings from this grid is consistent night and resting pain, and pain prior to end-range ROM; not just at end-range. Other mechanical pathologies should not directly resemble this.

Presence of Nodules in Posterior and Lateral Deltoid and Biceps Brachii

Another examination finding that I find to aid in differentiating RTC pathology from stage 2 freezing shoulder is the presence of nodules in the muscle of lateral deltoid, posterior deltoid and biceps brachii.  The skeletal muscle can be felt fairly easily in these areas. Theoretically, the inflammation that has formed in the GHJ gets carried with gravity south into the soft tissue structures, where it stagnates.

-I find that the more distal the nodules (closer to elbow), the higher irritability classification is present.

-This also correlates with a treatment approach that can be used, entitled Niel-Asher Technique.  You can learn more about it here.

The following is similiar to table 3 presented by Kelley et al as shown above but has been adjusted for “freezing shoulder” and specifically examination findings that I find are key.  It does not include pt age, past medical history, and other subjective information that is crucial; but more objective conclusions.

1. Significant pain, even at rest (basically high irritability) and all end-ranges more painful than at resting state.

2. 50% or > than 30 deg loss of passive ER & (+) external rotation test.

3. > 25% weakness of IR and pain with break testing.

4. (+) nodules present lateral & post deltoid & biceps.  More distal = higher irritability.

As with any diagnosis, there is not one “special test” or clinical procedure for physical therapists to make a punctilious diagnosis; but I feel the above 4 examination procedures of pain, strength, ROM loss & palpation are key to determining “freezing shoulder”.

What are your thoughts about the diagnostic information listed above? Do you feel this is on track and if this is not what you see clinically, what else would you add or take away?

Kelley MJ, McClure PW, Leggin BG.  Frozen Shoulder: Evidence and a Proposed Model Guiding Rehabilitation.  JOSPT. 2009: 39(2); 135-148.

Wolf EM, Cox WK.  The External Rotation Test in the Diagnosis of Adhesive Capsulitis.  Orthopedics.  May 2010.