Idiopathic adhesive capsulitis - A prospective functional outcome study ofnonoperative treatment

Background: Idiopathic adhesive capsulitis is a commonly recognized but poo rly understood cause of a painful and stiff shoulder. Although most orthopa edic literature supports treatment with physical therapy and stretching exe rcises, some studies have demonstrated late pain and functional deficits. T he purpose of this study. was to evaluate the outcome of patients with idio pathic adhesive capsulitis who were treated with a stretching-exercise prog ram. Methods: Seventy-five consecutive patients (seventy-seven shoulders) with p hase-II idiopathic adhesive capsulitis were treated with use of a specific four-direction shoulder-stretching exercise program and evaluated prospecti vely, The initial evaluation included the recording of a detailed medical a nd orthopaedic history and assessment of pain, range of motion, and functio n. The outcome evaluation included assessment of pain, range of motion, and function; completion of the Disabilities of the Arm, Shoulder, and Hand (D ASH) Questionnaire; and completion of the Short Form-36 (SF-36) Health Surv ey, 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 thre e patients were lost to follow-up. Results: Sixty-four (90 percent) of the patients reported a satisfactory ou tcome. Seven (10 percent) were not satisfied,vith the outcome, and five (7 percent) underwent manipulation and/or arthroscopic capsular release. The o utcomes of the patients who did not have manipulation or capsular release w ere evaluated. There were significant improvements in the scores for pain a t rest (from a mean of 1.57 points before treatment to a mean of 1.16 point s at the final evaluation; p < 0.001) and pain with activity (from a mean o f 4.12 points before treatment to a mean of 1.33 points at the final evalua tion; p < 0.0001). On the average, active forward elevation increased 43 de grees, active external rotation increased 25 degrees, passive internal rota tion increased eight vertebral levels, and the glenohumeral rotation are 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 (o f a possible twelve) to a mean of 10.75 (p < 0.00001). Despite the signific ant improvements and the high rate of patient satisfaction, there were stil l significant differences in the pain and motion of the affected shoulder w hen compared with those of the unaffected, contralateral shoulder (p < 0.00 001). At the final outcome evaluation, the DASH scores demonstrated limitations w hen 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 ev entual need for manipulation or capsular release. Male gender and diabetes mellitus mere associated with worse motion at the final evaluation. Patient s with a greater severity of pain with activity at the initial evaluation h ad significantly lower DASH scores at the final evaluation, and patients wi th 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 adh esive 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 acc eptable to most of the patients and did not affect their general health sta tus. Patients with more severe pain and functional limitations before treat ment had relatively worse outcomes. More aggressive treatment such as manip ulation or capsular release was rarely necessary, and the efficacy of early use of these treatments should be further studied.