Frozen Shoulder Capsulitis Rehabilitation Protocol

This protocol provides a comprehensive physical therapy rehabilitation program for patients diagnosed with Frozen Shoulder Capsulitis (Adhesive Capsulitis). The protocol is divided into three phases, focusing on pain management, restoring range of motion, and functional return. Progression through the phases is dictated by the patient's tolerance and clinical presentation. It is crucial to individualize the program based on the patient's specific needs and progress. Careful monitoring of symptoms and consistent communication between the therapist and patient are essential.

Pathophysiology

Frozen shoulder, or adhesive capsulitis, is characterized by progressive pain and significant restriction of active and passive shoulder motion in all planes, particularly external rotation. The pathophysiology involves inflammation and subsequent fibrosis of the glenohumeral joint capsule, leading to thickening and contracture. This process restricts the normal gliding and rotation of the humeral head within the glenoid fossa. The exact etiology is often unknown (primary adhesive capsulitis), but it can be associated with systemic diseases (diabetes, thyroid disorders), trauma, or prolonged immobilization (secondary adhesive capsulitis). The condition typically progresses through three phases: Freezing (painful and progressive loss of motion), Frozen (painful but with limited motion), and Thawing (gradual return of motion).

Common Special Tests

• Apprehension Test: Assess glenohumeral instability.
• Relocation Test: Following a positive apprehension test, apply a posterior force to the humerus. Relief of apprehension suggests anterior instability.
• Neer Impingement Test: Forced shoulder flexion in internal rotation; positive if it reproduces pain, suggesting impingement.
• Hawkins-Kennedy Test: Shoulder and elbow flexed to 90 degrees, then internally rotated; positive if it reproduces pain, suggesting impingement.
• Empty Can Test (Supraspinatus Test): Shoulder abducted to 90 degrees, forward flexed 30 degrees, internally rotated (thumb down), and resistance applied; tests supraspinatus strength.
• External Rotation Lag Sign: Patient actively holds shoulder in maximal external rotation at 20 degrees abduction. Inability to maintain position suggests infraspinatus or teres minor weakness/tear.
• Internal Rotation Lag Sign (Lift-Off Test): Patient attempts to lift hand off their back while the therapist resists. Inability to lift off suggests subscapularis weakness/tear.

Phase I: Protection (Pain Control and Minimize Inflammation)

Goals:

• Reduce pain and inflammation.
• Minimize further stiffness.
• Patient education on activity modification.

Treatment (Typical Duration: 2-6 weeks):

• Pain Management:
• Modalities: Ice, heat (dependent on patient preference), TENS unit, ultrasound.
• Gentle joint mobilizations (Grade I and II) to maintain joint nutrition and reduce pain.
• Soft tissue mobilization to surrounding muscles (scapular muscles, rotator cuff).
• Medication management (with physician): NSAIDs, analgesics.
• Range of Motion (ROM):
• Pendulum exercises (circumduction, flexion, extension) – 2-3 times daily.
• Active Assisted ROM (AAROM) with a pulley system or wand for flexion and abduction within pain-free range.
• Gentle passive ROM (PROM) in pain-free ranges, focusing on external rotation. Avoid forcing movement beyond pain tolerance.
• Scapular stabilization exercises (scapular retractions, protractions, upward/downward rotation) - low intensity, high repetition.
• Education:
• Activity modification to avoid aggravating activities.
• Proper posture and body mechanics.
• Importance of adherence to the home exercise program.

Progression Criteria: Patient demonstrates decreased pain at rest and with activity, improved pain-free ROM, and active participation in the home exercise program.

Phase II: Loading (Restore Range of Motion and Strength)

Goals:

• Increase range of motion in all planes.
• Improve strength and endurance of rotator cuff and scapular muscles.
• Restore normal scapulohumeral rhythm.

Treatment (Typical Duration: 4-8 weeks):

• Pain Management: Continue with modalities as needed for pain control.
• Range of Motion (ROM):
• Joint mobilizations (Grade III and IV) to address capsular restrictions.
• Progress PROM exercises to increase end-range motion.
• Continue AAROM exercises.
• Begin active ROM (AROM) exercises in all planes.
• Stretching exercises: Cross-body adduction stretch, sleeper stretch for posterior capsule, towel stretch for internal rotation, doorway stretch for anterior capsule. Hold stretches for 30 seconds, repeat 3-5 times.
• Strengthening:
• Isometric exercises for rotator cuff muscles (internal rotation, external rotation, abduction, scaption).
• Progress to isotonic exercises (theraband or light weights) for rotator cuff and scapular muscles, focusing on controlled movements.
• Examples: External rotation, internal rotation, scaption, abduction, rows, scapular retractions, shoulder press.
• Begin plyometric exercises (ball toss against wall) once sufficient strength is regained and pain is minimal.
• Proprioception:
• Weight bearing exercises (e.g., quadruped position with weight shifting).
• Perturbations on unstable surfaces (e.g., balance board).

Progression Criteria: Patient demonstrates significant improvement in ROM, increased strength and endurance, minimal pain with activity, and good understanding of proper exercise technique.

Phase III: Return to Function (Optimize Function and Prevent Recurrence)

Goals:

• Restore full and pain-free ROM.
• Maximize strength, endurance, and power.
• Return to pre-injury level of function and activity.
• Prevent recurrence.

Treatment (Typical Duration: 2-4 weeks):

• Range of Motion (ROM): Continue stretching as needed to maintain full ROM.
• Strengthening:
• Progress strengthening exercises to higher resistance and more functional patterns.
• Continue plyometric exercises with increased intensity.
• Introduce sport-specific or activity-specific exercises.
• Address any remaining muscle imbalances.
• Endurance Training:
• High-repetition, low-load exercises to improve muscular endurance.
• Progress to longer durations of functional activities.
• Functional Training:
• Simulate activities related to work, sports, or daily living.
• Gradually increase the intensity and duration of activities.
• Maintenance Program:
• Develop a home exercise program to maintain strength, ROM, and flexibility.
• Educate the patient on proper body mechanics and injury prevention strategies.

Discharge Criteria: Patient demonstrates full and pain-free ROM, adequate strength and endurance to perform desired activities, and a good understanding of a maintenance program to prevent recurrence. The patient is able to return to their pre-injury level of function.

Note: This protocol is a guideline and should be adapted to meet the individual needs of each patient. Regular monitoring of symptoms and open communication between the therapist and patient are crucial for successful rehabilitation.