1. The Stiff Shoulder

2. Normal Anatomy The glenohumeral joint is surrounded by a capsule Parts of the capsule are thicker and are identified as ligaments

3. Restraints To Motion Limitation in External rotation at 0° – Coracohumeral Ligament – Superior Glenohumeral Ligament Limitation in External Rotation at 45° – Middle glenohumeral ligament Limitation in External Rotation at 90° – Anterior Band of Inferior Glenohumeral Ligament

4. Restraints To Motion Limitation in Internal rotation at 0° and 45 ° – Posterior Capsule Limitation in Internal Rotation at 90° – Posterior Band of Inferior Glenohumeral Ligament

5. Pathophysiology No agreement on pathophysiology Elevated cytokines levels cause continued inflammation and fibrosis Presence of inflammation disputed Agreement on presence of capsule fibrosis

6. Classification

8. Associated Pathologies Diabetes Thyroid Rheumatoid arthritis Scleroderma Cardiovascular disease

9. Stages StageNameTime FramePainROMArthroscopic Findings 1Painful0 – 3 MonthsAt end range90-100%Synovitis No capsular fibrosis 2Adhesion3 – 6 MonthsSevereGlobally Restricted Synovitis, Inferior capsule adheres to humerus 3Frozen6 – 12 MonthsAt end of available range Globally Restricted Burned out synovitis, fibrosis of capsule 4Thawing15 – 24 MonthsAt end of available range Gradually Increases Information not available

10. Subjective Dependent on stage Insidious onset (can be traumatic or post operative) Gradual increase in pain Disturbed sleep Restricted painful range of movement

11. Subjective More Night Pain More Pain More Stiffness = More Synovitis Less Synovitis, More Fibrosis

12. Objective Dependent on stage Global loss ROM External Rotation Restriction Active = Passive ROM Capsular End Feel or Muscle Spasm End Feel

13. Further Investigation MRI can be used to rule out other pathology Otherwise diagnosis is made clinically

14. Conservative - Management Dependent on stage and irritability Physiotherapy is aimed at restoring MOBILITY Soft tissue work is used to prepare tissues Joint Mobilisations are KEY Heat is applied in all stages Strengthening can be continued once range of movement allows

15. Conservative - Management Highly Irritable, Severe Pain, Lots of Night Pain, End Feel due to Muscle Spasm – Soft tissue work – Low Grade Mobilisation – Regular light Active Range of Movement HEP Minimal Irritability, Pain at end range, Capsular End Feel – Aggressive Mobilisation – Low Load, Long Duration Stretching

16. Conservative - Management Know your capsular pattern and Arthrokinematics to target specific parts of the joint

17. Surgical - Management Manipulation Under Anaesthetic Arthroscopic Capsular Release