Frozen Shoulder (Adhesive Capsulitis) - SOAP Format Assessment & Management

BACKGROUND

S - SUBJECTIVE

Chief Complaint

• Gradual onset of diffuse shoulder pain and progressive stiffness, usually unilateral
• Often spontaneous onset; patient may recall minor trauma of unknown relevance

History of Present Illness

• Onset & Duration: Typically weeks to months; course lasts 1-2 years (longer in diabetics)
• Pain character: Dull ache at rest, sharp at end-range; classically described as diffuse, difficult to localize
• Aggravating factors: Overhead reach, lying on the affected side, sudden movements, reaching behind the back
• Relieving factors: Rest, heat, analgesics
• Night pain: Common and often chief complaint early in course
• Functional limitations: Difficulty dressing (fastening bra, putting on coat), combing hair, reaching overhead shelves, washing opposite axilla
• Phase-specific symptoms:
  • Phase 1 - Painful (Freezing): Severe pain, gradual loss of motion; lasts 2-9 months
  • Phase 2 - Stiffening (Frozen): Pain lessens but severe stiffness persists; lasts 4-12 months
  • Phase 3 - Thawing: Gradual return of motion; pain diminishes; lasts weeks to months

Past Medical History

• Diabetes mellitus (bilateral disease in 50% of diabetics)
• Thyroid disease, cardiac disease
• Contralateral frozen shoulder (20-30% develop opposite shoulder)
• Prior shoulder injury, surgery, or prolonged immobility
• Depression/anxiety (adversely affect symptoms and function)

Medications

• Current analgesics, NSAIDs, corticosteroids, anti-diabetic drugs
• Previous injection therapy

Social History

• Occupation (overhead work, sedentary desk job - note posture)
• Dominant hand involvement (predictive of better outcome)
• Activity limitations at home and work

Patient Goals

• Pain reduction, return of motion, independence in ADLs

O - OBJECTIVE

Observation / Posture

• Guarding of the affected shoulder; arm held adducted and internally rotated
• Muscle atrophy (deltoid, supraspinatus) in prolonged cases
• Scapular compensatory elevation during arm elevation attempts

Palpation

• Tenderness over the glenohumeral joint, anterior capsule, and coracohumeral ligament
• No redness or warmth (helps differentiate from septic arthritis)
• Palpable stiffness of the shoulder girdle

Range of Motion (Active & Passive)

Key finding: Global loss of both active AND passive motion, especially external rotation. - Bailey & Love's Surgery 28th Ed, p.552

Strength Testing

• May appear weak due to pain inhibition; true rotator cuff strength relatively preserved
• Supraspinatus (empty can / Jobe's test), infraspinatus, subscapularis testing to rule out cuff tear

Special Tests

Outcome Measures

• VAS or NPRS: Pain at rest and with movement (0-10)
• DASH / QuickDASH: Upper limb disability
• ASES (American Shoulder and Elbow Surgeons) Score
• Oxford Shoulder Score
• SPADI (Shoulder Pain and Disability Index)

Imaging (if available)

• X-ray: Normal - used to rule out OA, fracture, calcific tendinitis
• MRI: Not routinely needed; may show capsular thickening, enhancing synovium
• Arthrography: Reduced joint capsule volume (confirms diagnosis but rarely needed clinically) - Goldman-Cecil Medicine, p.2777

A - ASSESSMENT

Diagnosis

Clinical Reasoning

• Global restriction of active AND passive GH motion in all planes, with disproportionate loss of external rotation
• Absent signs of infection (no redness, warmth), normal X-ray ruling out OA/fracture
• Associated risk factors (e.g., diabetes, age 40-70, female sex)
• Pathological process: synovial inflammation → capsular fibrosis → contracture of axillary fold and coracohumeral ligament

Differential Diagnoses to Exclude

• Rotator cuff tear (passive motion relatively preserved; positive drop arm, weakness in ER/abduction)
• Osteoarthritis (X-ray changes, older age, crepitus)
• Calcific tendinitis (X-ray shows calcium deposits, acute severe pain)
• Septic arthritis (redness, warmth, fever, systemic signs)
• Glenohumeral OA
• Cervical radiculopathy (neck pain, dermatomal sensory loss, radicular symptoms)

Functional Impact

• Limited independence in ADLs: dressing, grooming, reaching, driving
• Sleep disturbance due to night pain
• Work and recreational limitations

Prognosis

• Predominantly self-limiting; traditional timeline 12-18 months, though ~10% have long-term problems
• Diabetic patients: longer course, lower rates of full ROM recovery (~71% vs 90% non-diabetic)
• Earlier presentation correlates with faster recovery
• Dominant shoulder involvement: associated with better outcomes - Campbell's Operative Orthopaedics 15th Ed, p.2840

P - PLAN

Phase 1 - Painful Phase (Priority: Pain Control)

• Gentle pendulum (Codman's) exercises - gravity-assisted passive motion
• Passive ROM within pain-free range, no forced stretching
• Heat (prior to exercise) and ice (post-exercise) for pain modulation
• TENS (transcutaneous electrical nerve stimulation) for pain relief
• Ultrasound therapy for tissue extensibility
• Patient education: nature of condition, expected timeline, importance of active participation

• NSAIDs (oral): ibuprofen, naproxen for inflammation and pain
• Corticosteroid injection: 1 mL methylprednisolone 40 mg/mL into glenohumeral joint and/or subacromial bursa - most beneficial in early/painful phase
• Oral corticosteroids: improve pain and ROM short-term

Phase 2 - Stiffening / Frozen Phase (Priority: Restore ROM)

• Progressive passive and active-assisted ROM exercises
• Capsular stretching: posterior capsule stretch, cross-body adduction stretch, sleeper stretch
• Glenohumeral joint mobilization (Maitland Grade III-IV): anterior, inferior, and posterior glides
• Muscle energy techniques (METs) for ER and shoulder flexion
• Pulley exercises and wall-climbing finger exercises
• Scapular stabilization exercises
• Thoracic spine mobilization (accessory mobility)
• Progressive active ROM and strengthening as tolerated

• Hydrodistension / distension arthrography: 20-30 mL of local anaesthetic + corticosteroid injected into joint capsule; facilitates ROM exercises - Bailey & Love's Surgery 28th Ed, p.552
• Continue NSAIDs and/or corticosteroid injections

Phase 3 - Thawing Phase (Priority: Restore Strength & Function)

• Progressive active ROM - full arc training
• Rotator cuff strengthening (ER, IR, abduction)
• Scapular stabilizer strengthening (serratus anterior, lower/middle trapezius)
• Proprioception and neuromuscular re-education
• Functional task training (ADL reintegration, overhead work)
• Gradual return to sport/work activities

Operative Management (Reserved for Prolonged/Refractory Cases)

1. Manipulation under anaesthesia (MUA): Closed manipulation; good results; failure usually due to inability to maintain postoperative motion
2. Arthroscopic capsular release: Recommended when MUA fails; releases tight capsule with emphasis on coracohumeral ligament
3. Open surgical release: Reserved for failure of arthroscopic release; emphasis on restoring rotator interval

• Campbell's Operative Orthopaedics 15th Ed, p.2841 notes MUA, arthroscopic release, and structured physiotherapy were equivalently effective in RCT, but arthroscopic release carried highest risk.

Patient Education

• Explain 3-phase self-limiting course and realistic timeline (1-2 years)
• Reinforce active exercise participation even during pain phase
• Educate on diabetes control (worsens prognosis and course)
• Address sleep positioning (avoid lying on affected side; use pillow support)
• Explain red flags requiring reassessment (fever, acute swelling, neurological symptoms)

Goal Setting (Short & Long Term)

• Short-term: Reduce pain (VAS <3/10), improve passive ER by 15-20°, sleep improvement
• Long-term: Restore functional ROM, independent ADLs, return to work/sport

Follow-up

• Reassess every 2-4 weeks
• Reassess and modify intervention based on phase progression
• Refer to orthopaedic/rheumatology if no improvement after 3 months conservative care

Summary