Case study on Adhesive Capsulitis Frozen Shoulder (Syn : Periarthritis, Adhesive Capsulitis)

Abu Saleh Alamgir

Dr. Md. Abu Saleh Alamgir

The term “Adhesive Capsulitis” should be reserved for a well defined disorder characterized by progressive pain and stiffness of the shoulder joint which usually resolves spontaneously after about 18 months. The cause remains unknown. The histological features are reminiscent of Dupuytren’s disease, with active fibroblastic proliferation in the rotator interval, anterior capsule and coraco – humeral ligament (Bunker and Anthony, 1995). The condition is particularly associated with Diabetes, Dupuytrens disease, Hyper lipidaemia, Hyper thyroidism, Cardiac disease and Hemiplegia. It occasionally appears after recovery from neuro surgery.

What is Adhesive Capsulitis: It may be defined as a clinical syndrome characterized by painful restriction of both active and passive movements of the shoulder joint due to causes within the shoulder joint (other parts of the body).

History of Adhesive Capsulitis: Dupley first described it in 1872 and called it as ‘Humero-Scapular Peri-arthritis. In 1934 Codman Coined the term ‘Frozen Shoulder’ and in 1945 Neviaser gave the name ‘Adhesive Capsulitis’.

Causes of Adhesive Capsulitis: Shoulder causes problems directly related to the shoulder joint which can give rise to Frozen Shoulder are tendinitis of the Rotator cuff, Bicipital tendonitis, Fractures and dislocation or sublaxation around the shoulder.

Non Shoulder causes problems not related to shoulder joint like Diabetes, Cardio-Vascular Diseases (CVS) with referred pain to the shoulder which keeps the joint immobile, reflex Sympathetic dystrophy, Frozen hand shoulder syndrome a complication of colle’s fractures can all lead to Frozen Shoulder. The reason could be prolonged immobilization of the shoulder joint due to referred pain.

Pathology of Adhesive Capsulitis: During Abduction and repeated overhead activities of the shoulder, long head of Biceps muscles and Rotator cuff muscles undergo repeated strain. This results in inflammation, fibrosis and consequent thickening of the capsule of the shoulder joint which results in pain and loss of movement of the Shoulder joint. If the movements are continued, then the fibrisis gradually breaks, movements return but never come previous physiological condition.

Prolonged activity causes small Scapular muscles and Biceps muscles to fibrosis faster and load on joint which results in increases and degenerative changes in the shoulder joint. Capsule is fibrosed and shoulder movements are decreased.

Clinical feature of Adhesive Capsulitis: The patients of middle aged may give a history of trauma, often trivial followed by aching in the arm and shoulder. Pain gradually increases in severity and often prevents sleeping disturbance on the affected side. After several month it begins to subside, but as it does so stiffness becomes an increasing problem, continuing for another 06-12 months after pain disappeared. Gradually movement is regained, but it may not return to normal and mild pain and decrease range of motion persist.

Apart from slight wasting, the shoulder looks quite normal, tenderness is seldom marked. The cardinal feature is a stubborn lack of active and passive movement in all direction.

Stages of the Adhesive Capsulitis: There are three Classical stages in Adhesive Capsulitis.

Stage – 1 (stage of pain): Patient complains of acute pain, decreased movements, external rotation greast followed by loss of Abduction and then forward flexion. Internal rotation is less affected. This stage lasts for 10 – 36 weeks. Pain due to limited range of motion (ROM) of shoulder usually will not radiate below the elbow unlike in Cervical Spondilosis.

Stage – 2 (stage of stiffness): In this stage pain gradually decrease and the patient complains of stiff shoulder joint. Slight movements of the shoulder joint are present.

Stage – 3 (stage of recovery): patient will have no pain and movements will have recovered but will never be regained to normal. It last for 06 month to 24 month.

Investigation of Adhesive Capsulitis: * X – ray of the Shoulder joint ( affected side ) B / V.

X – ray are normal unless they show reduced bone density from disuse.

Their main value is to exclude other causes of a painful, stiffness of the shoulder joint.

* Blood for TC, DC, Hb% and ESR.

Diagnosis of Adhesive Capsulitis: Every painful shoulder or stiffness shoulder is not Frozen Shoulder and indeed there is some controversery over the criteria for diagnosing ‘ Frozen Shoulder ‘ (Zuckerman et al-1994). Stiffness occurs in a variety of condition – Arthritic, Rheumatic, Post traumatic and Post operative. The diagnosis of Frozen Shoulder is clinical, resting on two characteristic features – (a) painful restriction of movement in the presence of normal X – ray and (b) a nature progression through three successive phases.

When the patient is first seen, a number of conditions should be excluded. Infection, post-traumatic stiffness, disuse stiffness and reflex sympathetic dystrophy.

Infection-In patient’s with Diabetes, it is particularly important to exclude infection. during the first day or two, signs of inflammation may be absent.

Post traumatic stiffness-After any severe shoulder injury, stiffness may persist for some months. It is maximal at the start and gradually lessens, unlike the pattern of a Frozen Shoulder.

Diffuse stiffness-If the arm is nursed over-cautiously (eg-following a forearm fracture) the shoulder may stiffen, Again the characteristic pattern of a Frozen shoulder is absent.

Reflex Sympathetic Dystrophy – Shoulder pain and stiffness may follow myocardial infarction or a Srtoke. The features are similar to those of a Frozen Shoulder and it has been suggested that the later is a form of reflex sympathetic dystrophy. In severe cases the whole upper limb is involved with tropic and vaso – motor changes in the hand. (The Shoulder – Hand Syndrome)

Differential Diagnosis: The Shoulder may be painful due to –

# Reffered pain syndrome- # Rotator Cuff disorder

” Cervical Spondylosis            * Tendinitis

” Mediastinal pathology           *  Rupture

” Cardiac ischaemia             * Adhesive Capsulitis

# Joint Disorder               # Instability

” Gleno – Humeral arthritis * Dislocation

” Acromio – Clavicular arthritis         * Subluxation


# Bony lesion – # Nerve injury –

” Infection  * Suprascapular nerve entrapment.

” Tumours

Confirm Diagnosis: For Adhesive Capsulitis –

For confirm diagnosis of the Adhesive Capsulitis we can do the “LAM” test. It has to do manually.

Here L – means Lateral Rotation, A – means Abduction and  M – means Medial Rotation.

This test have to perform passively by Physiotherapist (PT).

Capsular Pattern test of the Shoulder joint –

– So much limitation of Abduction,

-More than that of lateral rotation,

– Less than that of Medial rotation

Note: Apprehension test indicates impending Frozen Shoulder.

– Pain during extreme passive abduction is an indicator of the future impending Frozen Shoulder.

Treatment of Adhesive Capsulitis

Surgical treatment: Surgery does not have a well – defined role. The main indication is prolonged and disabling restrict- tion of movement which fails to respond to conservative treatment. The Rotator interval and coraco- humeral ligament are released and the coraco -acromial ligament is excised. This can be achieved arthroscopi- cally, although for difficult cases open operation is safer (Warner – 1997).

Conservative treatment: Conservative treatment aims to relieve pain and prevent further stiffening while recovery is awaited. It is important not only to administer analgesic and anti – inflammatory drugs but also to reassure the patient that recovery is certain.

Exercises are encouraged.

The real culprit for the shoulder stiffness is the thick and contracted capsule of the shoulder joint. Efforts are targeted at softening this capsule by passive mobilization.

Methodology of the Case Study: The study was experimental type of prospective survey to explore patients functional outcome. The sampling of the study was purposive and selected conveniently from the Physiotherapy center of the ” ISLAMI BANK CENTRAL HOSPITAL KAKRAIL (IBCHK).

For doing this study at first we selected 30 Patients. Then we taken the history and condition of the patients for this purpose and finally we selected 20 patients or samples for this study. Here we include both Mala and Female patients, whose age between 35-55 yrs. According to their age and sex again we devide them in to three groups. They are Group – A (10 Patients), Group – B (05 Patients) and Group – C (05 Patients).

For this experiment we have given Group -A (10 Patients)  Mannual Therapy with Thermotherapy. Group – B (05 Patients) only Mannual Therapy. Group – C (05 Patients) only Thermotherapy.

Inclusion Criteria: According to Mechanical pain, both Male and Female Patients were taken, here age limitation between (35 – 55) years.

Exclusion criteria: According to pathological pain, traumatic pain, sensory disturbance because of the ability to provide a surface at elevated temperature for prolong contact, it can and lead to accident burns (Diller K -1991) hypertensive skin, acute inflammation, acute fracture, Hypertension, Diabetes, Varicose vein etc. condition thermotherapy have to be given very carefully.

Measurement Tools: Visual Analogue Scale (VAS) was used to measure the pain intensity before and after completion the treatment of only manual therapy for Group – B, Only thermotherapy for Group – C and Manual therapy with thermotherapy for Group – A.

Visual Analogue Scale (VAS): Visual Analogue Scale is simple and accurate way of subjectively assessing pain along a continuous spectrum. The Visual Analogue Scale consists of a Straight line on which the individual being assessed, marks the level of pain. The ends of the straight line “10” represents the worse pain ever experience where “0” indicates no pain. (Carisson M – 1983).

Setting: Physiotherapy center of ” ISLAMI BANK CENTRAL HOSPITAL, KAKRAIL ” (IBCHK).

Duration of data collection: The entire data was collected within six month.

Confounding variables: Medication and Advise therapy which were controlled through the case study.

Result of the Study: From the case study of the 20 patients in the experimental group through the measurement of visual analogue scale. It was found that the Manual therapy is not that effective to decrease pain and increase ROM and the thermotherapy is not effective to reduce the pain and increase ROM.The Mannual therapy and Thermotherapy combindly help for the said condition we got the good result hat decreased pain and increase ROM of the Shoulder joint.

The patients have taken other kinds of treatment which also might affect the outcome of the result. For exm. Different type of medication also can reduce pain. But the pretest score was taken just before the application of Mannual therapy and Thermotherapy and post test score was taken after application of the Mannual therapy and the Thermotherapy. So any changes between the score would indicate because of the having application of this treatment

Limitation of the Case study: To choose the kind of methodology, actual or appropriate experimental design for this tropics, the appropriate condition of the people’s that are related to this modalities, to maintain the duration of treatment procedure for this condition, the correct application of the Mannual therapy and the Thermotherapy to the specific area of pain, the finding of the outcome, to compare Mannual therapy with other therapy and Thermotherapy with other kind of heat modalities to compare the selection of Mannual therapy with Thermotherapy with other kinds of treatment procedure. for this case study have to given more concentration on this modality because of it is effective or not. This is why this methodology was chosen.


The result of the case study have identified the effectiveness of Mannual Therapy with Thermotherapy to reduce the stiffness and relief the Shoulder pain.

In my country, Physiotherapy is still a relatively new profession and there is often a lack of awareness among the general public and also other health care professionals about the role of the Physiotherapy. In order to improve the awareness to the general public and also other health care professionals, it is the need of timing to ensure the applicati- on of the profession have to evidence based.


Further case study can be done to complete the efficacy among the other treatment procedure.


Special thanks to my honorable teacher Prof. Dr. Altaf Hossain Sarker for his proficient guidance. I would like to thank to “Islami Bank Central Hospital, Kakrail (IBCHK)”

for giving permission for this study.

I am grateful to those patients for give me extra time and attention for the study questionnaires voluntarily and cooperatively.

About Author

Born at 1982 at Noakhali District, Begumganj Thana, Alyarpur village, Seraj Mastarer bari.


SSC from Nakhalpara Hossain Ali High School -1997.

HSC from Tejgaon College -1999.

BPT Under Medicine Faculty of Dhaka University – 2004.

MD from Open University of India – 2007.

MPH on BackPain from American International University Bangladesh -2011.

Ph.D on BackPain from American World University, California, USA -2013.

Working Experience

Assistant Professor and Head of the Department

Department of Physiotherapy

Dhaka College of Medical Technology

Ex. Lecturer: Department of Physiotherapy

The People’s University of Bangladesh

Consultant: Department of Physiotherapy

Al-Rafi Hospital Private Limited

Senior Physician: Department of Physiotherapy

Islami Bank Central Hospital

Examiner: Bangladesh Technical Educational Board

Contact Number: 01712808548, 01556391350.