Identifying Early Signs and Symptoms of Adhesive Capsulitis

image In my opinion, one of the most challenging disorders of the shoulder to properly diagnose during the early stages is adhesive capsulitis, or frozen shoulder.  Let me explain that further – once a person has global tightness and loss of motion, this is a pretty easy diagnosis.

But I often wonder if some of our patients with “shoulder pain” but not loss of motion may actually have stage one irritation of the capsule that could develop into adhesive capsulitis.

If we can work with patients during this phase, maybe we can stop the process?  Maybe we can prevent severe loss of motion?  Unfortunately to date, there has been many anecdotal advice but no consensus on the clinical identifiers or early stage adhesive capsulitis.

A recent article in the Journal of Physical Therapy sought to develop a consensus among a group of experts regarding clinical identifiers for the first stage of adhesive capsulitis (Abstract here or if you are a subscriber of PT you can view full article here)  The author’s used the Delphi technique (more information on the Delphi Technique here) to poll a group of experts within the fields of rehabilitation medicine, physical medicine, orthopedic surgery, physical therapy, chiropractic, and osteopathy.

After polling and statistical analysis, the authors report 8 factors that the group agreed upon as being strong clinical indicators of early stage adhesive capsulitis:

  • There is a strong component of night pain
  • There is a marked increase in pain with rapid or unguarded movements
  • It is uncomfortable to lie on the affected shoulder
  • The patient reports the pain is easily aggravated by movement
  • The onset is generally in people greater than 35 years old
  • On examination, there is global loss of active and passive range of motion
  • On examination, there is pain at the end range of motion
  • There is a global loss of passive glenohumeral joint movement

These factors were all selected and narrowed down from an original list of 60 items that is included in the manuscript.  I thought it was interesting that many of the clinical identifiers that I use did not make the final consensus.  For example, none of the below reached consensus:

  • The onset is generally in people less than 60 years old
  • The condition more commonly presents in females
  • There can be an association with diabetes

Perhaps these are stereotypes that I have used in my practice based on past anecdotal advice.

Clinical Implications

The results of this study in no way should be used as strict criteria in the diagnosis of adhesive capsulitis, but may provide some useful guidance during the subjective and objective portions of your exam.  I would suggest integrating the above information into your examination.

I always recommend that you carefully exam someone that comes to you with “shoulder pain”   to try to identify signs and symptoms of early stage adhesive capsulitis.  As we all know, this pathology can have severe complications on the individual’s functional status, anything we can do to identify and prevent the progression would be extremely helpful.

Walmsley S, Rivett DA, & Osmotherly PG (2009). Adhesive capsulitis: establishing consensus on clinical identifiers for stage 1 using the DELPHI technique. Physical therapy, 89 (9), 906-17 PMID: 19589853

18 replies
  1. Tim Mazzola
    Tim Mazzola says:

    As a nonsurgical Orthopedic and Sports Medicine Physician who successfully treats alot of folks with frozen shoulder, I have been fortunate to help many patients achieve significant improvements with ultrasound guided glenohumeral joint and capsular distensions and injections, followed by excellent PT. Unfortunately, I’m now the guy with crazy left shoulder pain that fits every one of the descriptors this expert group came up with for EARLY frozen shoulder.

    As others have mentioned, the amount of pain involved really is impressive.

    My study of the condition (as I lecture on it) has led to the realization that in the early phase, histological tissue analysis shows there is rampant inflammation of the joint capsule. This fits with the palpatory tenderness along the anterior and posterior joint lines, as well as the restricted motion, pain all the time and worse when stretching this inflamed capsule with motion and sidelying. This would explain why early steroid injections can be helpful. I will be seeing my ultrasound Sports Medicine colleague this week in hopes of obtaining just such an injection into the glenohumeral joint and capsule. This should help diminish pain, and allow the PT to better help mobilize the joint.

    For those folks later on in the condition (after first 2-3 months), the joint capsule loses all those vessels and inflammation, and it shrinks down and becomes avascular (no vessels). Think a grape becoming a raisin as it dehydrates, shrivels and thickens. It also becomes more leathery. Sometimes I’ll even find calcifications in the capsule with ultrasound guided injections. In any case, at this later stage, steroids can still help, but capsular distension with high volumes of sterile saline really open up the joint capsule. Think filling up a water balloon as it distends. Followed by excellent PT and even some in-office manipulations and muscle energy techniques has literally “changed peoples’ lives” in one visit multiple times.

    So, I add to the conversation, as I think this information needs to get out there.

    Thanks, Mike, for a great site with lots of practical information. You blessed this doctor with your “consensus review” of early frozen shoulder symptoms- it will help me help many others as well. I’ve definitely learned alot of empathy and compassion for my patients who suffer with this very painful condition!

  2. Dino Pappas
    Dino Pappas says:

    I like some of the points mentioned above. I’d like to add something to the mix that’s generally not discussed with frozen shoulder and that is the correlation to the cervical spine. In each case that I’ve been seeing lately of diagnosed frozen shoulder (whether I made the diagnosis or it has been referred into my practice), there has been a cervical correlation. Namely, rule out the cervical spine first and then if needed assess and treat the shoulder. This is in line with the McKenzie Method philosophy for the extremities. What I’ve found is that some improve and even clear up without the practitioner aggressively treating the shoulder complex with mobilization, manipulation, or soft tissue methods. The repeated movement assessment is critical here in finding out whether the cervical spine is a player. There are case reports and case series in the literature of cervical treatments alone helping resolve frozen shoulder. If no further improvement in ROM or pain after repeated cervical testing and treatment, then assessment of the shoulder is warranted. Using this thought process, I’ve imparted way less discomfort into patients and the results with rapid improvement are possible. I would love to hear your thoughts and comments. – Dino

  3. Name (required)
    Name (required) says:

    This is my second bout with this insidious disease, first the left – 2009-2011(non-dominant arm), and now the right shoulder (first twinges felt in April 2012). I am currently slowly (as of a few days ago slowly beginning to get some relioef from this passive, constant pain which started in mid-September 2012, marking my progression to the frozen stage).

    From the first occurrence, I came to seriously wonder if indeed the medical professionals really knew a lot about it. No one seems to recognize the excruciating pain, especially during the so-called “frozen stage” – not even the orthopedist. I saw 3 of them before I found one who was willing to actually give me some medication for this horrible pain. During this frozen stage, the pain is not only agonizing but literally 24-hours around the clock, affecting sleep – and quality of life. Not only is the pain in the shoulder itself, but sometimes equally as intense in the elbow and wrist. In fact the entire arm – long bones, muscles, fingers, palm of the hand, clavicle, scapula – everywhere and everthing hurts. There is also a good deal of stiffening of the neck and back muscles, I suppose because of compensation. Combing hair and dressing is a painful challenge. I feel that this disease takes me out of my life (literally), and the life out of me – it is extremely draining.

    First time in 2009, I went to PT for 5 months, with not much progress, as far as regaining ROM. I gave up when I could no longer bear the manual manipulations attempted by the therapist, which I feel were not appropriate – except under anesthesia. I am a pretty stoic person who has had quite a few painful medical events in my life, but this has brought me to tears – and literally to my knees many a time.

    My doctor then, as a next step, suggested surgery to release the shoulder. However, in all the research I had done on line, each article would suggest that surgery should be the last consideration. And besides, I would still have to return to PT from the next day. After careful thought, I decided to work on my own at home first, using a program of exercises, together with elastic bands, provided by the PT. Eventually, after another 5 months, I found that I was beginning to regain use of my arm, but it took another 6 months or so before I would consider that I was healed.

    This time around, I decided to try to work on the right shoulder on my own – from the very beginning, in the hope that somehow, I would be able to prevent the progression, but no. I woke up one morning in mid-September 2012 only to realise that the “beast” (as I call it) was back! I persevered at home, but finally gave in and went to see the same orthopedist at the end of November, when I could no longer bear the pain.

    Despite the fact that there is wdely dcumented evidence of the extremely painful nature of this condition, I feel that while the pain experienced from certain conditions, e.g., migraines, post-surgical procedures, etc., are accepted, recognized, and adequately treated, the same is not true for AC. As a matter of fact you wonder if people (including the doctors) are convinced that the pain described could not possibly be – and is being grossly exaggerated. It just seems that a prescription for pain medication is somewhat reluctantly given.

    Let me say, that this denial of the pain a person is experencing is most frustrating and sometimes almost as painful as the disease itself. In the meantime, I continue to make very slow, painful progress, by the grace of God (lots of prayers – and calling prayer group), application of hot and cold pads, and I’ve gone through several large tubes of BenGay Ultra-Strength rub, without which I’m sure I would have gone mad from the pain.

    I wish strength and blessings for all those dealing with this “beast”!

    • Georgina
      Georgina says:

      You are spot on with all these symptoms. I’m dealing with this now, the second time in four years. Unbelievable pain and no respite for two months. I now feel the other shoulder starting again, and, like you, know that it will progress without being able to stop it. Unable to do anything during the day and feel completely useless.

    • Denise Dugal Marcucci
      Denise Dugal Marcucci says:

      Just got back from hospital clinic where was disgnosed with frozen shoulder…have been experiencing the worst pain for about 3 months…was told could take two years to get better, recommended physio and a shot that they will give me in hospital…I have a pretty good pain tolerance and this pain is almost unbearable..and it radiates into my wrist and hand…being my predominant arm it makes life really dificult, cannot dry my hair anymore, even getting dressed is tricky…I will try and do the exercises that they recommended at home too…hoping physio does not cause too much pain as it can be so painful.

  4. Christie
    Christie says:

    Dear Oldnight nurse,

    You are probably past the early stage and have moved on to actual loss of motion. Some people call this the "frozen" stage. It's relatively easy to identify this group with a clinical exam (in my opinion anyway) because the loss of motion is so compelling.

    Mike is specifically referring to the early stage (or freezing) where the diagnosis becomes less clear. Patients are often misdiagnosed has having "bursitis", "impingement syndrome" "tendonitis". These patients are often sent to physical therapy where it really just gets worse. Aggressive range of motion at this early stage really does nothing but to make it more inflammed. So here's where it becomes a little less clear as to what to do. Should we just wait and let things settle in and calm down, or is there a real solution we can offer this early stage group without making it a whole lot worse?

    Don't get me wrong though, frozen stage can be just as frustrating. Anecdotally, I find 1-2 sessions good soft tissue work helps this group prior to resuming range of motion. But they are in for an arduous course of care…some of which the literature contradicts. It's been suggested that no therapy is just as good as treatment…but thats not a comfort to most patients.

    As far as your questions about pain radiating to the hand. Many will argue that shoulder related pain, and espeically numbness and tingling cannot be realted to shoulder disorders. I would anecdotally disagree. A good inflammed shoulder can certain make that pain drop below the elbow. And many people with rotator cuff tears experience numbness and tingling…it's just not in a pattern like is does for a pinched nerve (ie, cervical in origin).

    Well, that's my two cents, anway. Good luck Ms. RN. Hang in there (no pun intended)

  5. oldnightnurse
    oldnightnurse says:

    I came across your blog while searching googling "adhesive encapsulitis severe night pain." I'm a 50 yr old RN, just diagnosed, and I can personally vouch for every one of your points above. I thought perhaps this wicked night pain had driven me to hypochondria because I am typically quite stoic. This, however, has driven me to tears a few times.

    I began having mild symptoms about 4-5 mos ago. Ever the optimist, I was just sure it would go away (in my dreams!) and knew it had to be related to tugging on patients. About a month ago, the pain became constant (mild to moderate still, unless there was sudden movement –> severe pain), ROM was decreasing, and it was painful when I tried to *make* myself move more.

    I've had x-rays and an MRI and am eating Motrin like M&M's as I await my appointment next Monday to see what the plan is… I do still try to move my arm as much as I can. but the pain is what prevents it. I don't know how much of the restriction is actually caused by the inflammation, but the pain is what stops me when and my ROM is decreasing more and more.

    Have any of you had patients with this who also c/o pain that radiates down the arm, into the elbow and hand as well? I've had major abdominal surgery twice and this pain at night rates right up there in its own way. No wonder I'm still awake at 2am and looking for answers, huh? God bless you all for what you do – hope I have a therapist as interested in this as you all are.

  6. Mike Reinold
    Mike Reinold says:

    @ JB – I agree that this is a common symptom that I see as well. Remember that this study just polled a large group of “experts” and came up with a collective group of signs and symptoms. Many of the items you mention were included in the study but did not reach consensus.

    @ Christie – I like your comment on pain less than a few months.

    @ Scott – I agree. I am starting to lean towards the thought that patients have adhesive capsulitis for much longer than we all realize before they actually seek attention. If you can do anything to break the inflammatory process, such as you suggest, you may potentially decrease the duration.
    This comes down to a state of mind for us clinicians – next time you see a patient with “shoulder pain” that you are treating for “impingement” etc., stop and think if it is possible that this is just very early adhesive capsulitis.

  7. Scott Deihl
    Scott Deihl says:

    I'd like to add to Jeff's comment/ question. Have you found that an fluroscopy guided intraarticular injection during the "freezing phase" assist the patient in moving past the "frozen phase" into the "thawing phase"? I have found if they sought attention early (and lucky enough to get in) they do well.

  8. Kory Zimney, PT
    Kory Zimney, PT says:

    Thanks for posting the article. I thought it was a pretty good study with some good info when I read it as well. I would also agree with your identification of diabetes. There is a tie, I also believe with diabetes. I think the sugar changes with diabetics and the tissue changes have a role in this.

    Also Christie, I would agree that Pain is a major factor and our ever growing understanding of pain and neural response will only help with our management of these patients.

  9. Christie Downing, PT, DPT, Dip. MDT
    Christie Downing, PT, DPT, Dip. MDT says:

    Anecdotally, I confirm much of the list…particularly, the night pain, inability to lay on the shoulder, and increase in pain with all motions.

    I'll also add that the pain is present less than a few months and that ROM is limited by PAIN, and not yet by restricted tissue.

  10. Jeff Cubos
    Jeff Cubos says:

    Add 1 more for the diabetes train.

    What treatment techniques have you all found helpful for treating this case. I personally have only found extremely slow mobilizations to be moderately successful. I'll also recommend the patient perform (very) LLLD stretches at home. Interestingly, some "patented" soft tissue technique practitioners strongly advocate for the use of their therapy and although I, myself, am fully certified, I have NOT found it beneficial at all (I'm a DC and many of us are certified in this technique if you catch my drift). ;-)

    Secondly, although many of us aren't radiologists how many of you had good results with fluoroscopic injections vs distension arthrograms?

  11. jb
    jb says:

    Hi Mike,
    Nice review of this piece. There is a major oversight in my opinion, like how about the fact that nothing is noted about soft tissue palpation findings (such as density in the latissimus dorsi in axilla or subacromial edema) or that limited inferior and posterior joint mobilization is present. Those are the skilled care findings that a physical therapist or other health care provider should be assessing to confirm the subjective findings.

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