The Journal of Bone and Joint Surgery 82:1398 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
Idiopathic Adhesive Capsulitis
A Prospective Functional Outcome Study of Nonoperative Treatment*
Sean M. Griggs, M.D. ,
Anthony Ahn, M.D. and
Andrew Green, M.D.
Investigation performed at the Shoulder Service, Brown University
School of Medicine, Rhode Island Hospital, Providence, Rhode Island
*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
Houston Hand and Upper Extremity Center, 1200 Binz Street, Suite
1200, Houston, Texas 77004.
Department of Orthopaedic Surgery, Hospital for Joint Diseases,
301 East 17th Street, New York, N.Y. 10003-3804.
§University Orthopedics, 2 Dudley Street, Suite 200, Providence,
Rhode Island 02905. E-mail address: andrew_green_md{at}brown.edu
Background: Idiopathic adhesive capsulitis
is a commonly recognized but poorly understood cause of a painful and
stiff shoulder. Although most orthopaedic literature supports treatment
with physical therapy and stretching exercises, some studies have
demonstrated late pain and functional deficits. The purpose of this
study was to evaluate the outcome of patients with idiopathic adhesive
capsulitis who were treated with a stretching-exercise program.
Methods: Seventy-five consecutive patients (seventy-seven shoulders)
with phase-II idiopathic adhesive capsulitis were treated with use
of a specific four-direction shoulder-stretching exercise program
and evaluated prospectively. The initial evaluation included the
recording of a detailed medical and orthopaedic history and assessment
of pain, range of motion, and function. The outcome evaluation included
assessment of pain, range of motion, and function; completion of
the Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire; and
completion of the Short Form-36 (SF-36) Health Survey. The mean
duration of follow-up was twenty-two months (range, twelve to forty-one
months). One patient died prior to the final evaluation, and three
patients were lost to follow-up.
Results: Sixty-four (90 percent) of the patients
reported a satisfactory outcome. Seven (10 percent) were not satisfied
with the outcome, and five (7 percent) underwent manipulation and/or
arthroscopic capsular release. The outcomes of the patients who
did not have manipulation or capsular release were evaluated. There
were significant improvements in the scores for pain at rest (from
a mean of 1.57 points before treatment to a mean of 1.16 points
at the final evaluation; p < 0.001) and pain with activity (from
a mean of 4.12 points before treatment to a mean of 1.33 points
at the final evaluation; p < 0.0001). On the average, active
forward elevation increased 43 degrees, active external rotation increased
25 degrees, passive internal rotation increased eight vertebral
levels, and the glenohumeral rotation arc at 90 degrees of abduction increased
72 degrees (p < 0.00001). The number of "yes" responses to the
Simple Shoulder Test increased from a mean of 4.1 (of a possible
twelve) to a mean of 10.75 (p < 0.00001). Despite the significant
improvements and the high rate of patient satisfaction, there were
still significant differences in the pain and motion of the affected
shoulder when compared with those of the unaffected, contralateral
shoulder (p < 0.00001).
At the final outcome evaluation, the DASH scores demonstrated
limitations when compared with known population norms, whereas the
profiles of the SF-36 were comparable with those of age and gender-matched
control populations.
Prior treatment with physical therapy and a Workers' Compensation
claim or pending litigation were the only variables that were associated
with the eventual need for manipulation or capsular release. Male
gender and diabetes mellitus were associated with worse motion at
the final evaluation. Patients with a greater severity of pain with
activity at the initial evaluation had significantly lower DASH
scores at the final evaluation, and patients with lower initial
scores on the Simple Shoulder Test had comparatively lower scores
on the Simple Shoulder Test at the outcome evaluation.
Conclusions: The vast majority of patients who
have phase-II idiopathic adhesive capsulitis can be successfully treated
with a specific four-direction shoulder-stretching exercise program.
Although measurable limitations and deficiencies were noted at the
outcome evaluation, these appeared to be acceptable to most of the
patients and did not affect their general health status. Patients
with more severe pain and functional limitations before treatment
had relatively worse outcomes. More aggressive treatment such as
manipulation or capsular release was rarely necessary, and the efficacy
of early use of these treatments should be further studied.
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