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‡ A 30-year-old male business project manager presents suffering from constant, mild,
dull generalized left shoulder pain that was precipitated by clicking and followed by a
gradual loss of motion. Particularly, the patient noted the inability to wash, comb his
hair, and retrieve his wallet from his back pocket.
‡ The patient began recreational weightlifting approximately one year prior to the onset
of his symptoms and noted that overhead movements and lateral dumbbell raises
increased his pain, and as such, were discontinued.
‡ Prior to the patient's presentation, radiographs of the left shoulder were exposed and
negative for fracture or dislocation. A brief course of over-the-counter anti-
inflammatory medications and rest provided no relief.
‡ The patient reported that his loss of motion came about gradually, and he was initially
in more pain. He stated that the pain tapered off, but his motion was reduced to the
point that all activities of daily living (ADLs) are performed with the use of his right
arm.
‡ A cervical, thoracic and bilateral shoulder examination was performed. The patient
tested negatively for cervical compression and thoracic outlet syndrome. Mild
restriction to osseous motion palpation was detected at T2 through T5. No bruits
were noted, and cervical vascular testing was within normal limits. There was no
tenderness to digital pressure over the bicipital tendon or groove, with resisted
supination of the forearm.
‡ Both passive and active ranges of motion were moderately decreased, with minimal
pain in the end ranges. Measuration via goniometer was as follows: flexion, 20/45;
extension, 20/45; abduction, 120/180; internal rotation, 20/55; external rotation,
10/45. Diffuse myospasm and active trigger-point nodules were palpable in the left
trapezius, deltoid and teres muscles.
‡ Postural evaluation noted elevation of the left shoulder as observed from the P-A
view.
 Three Phases of Primary Frozen Shoulder

‡ Stage I involves pain

‡ Stage II pain and restricted movement
‡ Stage III, involving painless restriction
 Treatment
‡ Treatment goals included increased of pain-free range of motion and restoration of normal, pain-free shoulder function.
‡ Treatment began at the acute intervention phase of rehabilitation. Manipulation of the shoulder joint was avoided during this stage, as
"some believe that overly aggressive manipulation can prolong the disorder.
‡ The fundamental goal of the acute phase of intervention was to reduce and decrease muscle spasm. This was accomplished through the
use of prescription ibuprofen (800 mg TID, as prescribed by the patient's primary care provider). In clinic, cryotherapy was administered at
a 15-minute duration, followed by aggressive sustained digital ischemic compression to areas of myospasm, with additional focus on
palpable trigger-point nodules located in the teres, trapezius and rhomboid muscles.
‡ Continuous ultrasound at 1.0w/cm2 was utilized with a hypoallergenic gel medium (continuous motion) to additionally reduce pain, spasm
and inflammation. The patient was treated passively three times per week for one week, with home instructions to begin incorporating left
arm movements in the pain-free range.
‡ By the patient's fourth visit, passive range of motion, ultrasound, digital ischemic compression and cryotherapy provided a substantial
increase in the pain-free active range of motion.
‡ On the fifth visit, light mobilization of the scapula was tolerated without difficulty. Additionally, diversified manipulation of the fixated
thoracic segments was introduced with the patient prone.
‡ These treatment protocols were administered during visits 5-7, in conjunction with PNF stretching utilizing a "stretch, hold, contract, relax"
method to increase passive range of motion (one set of five repetitions of 10 seconds).
‡ By the patient's eight visit, "wall walking" was introduced and performed for three sets of five repetitions to 60 degrees of 90 degrees,
pain-free. At the same time, pendulum exercises were instituted, unweighted in the clockwise, counter-clockwise and figure-eight motions.
Active protocols were preceded by ultrasound and followed by cryotherapy for visits 8-10.
‡ Visit 10 introduced weighted pendulum exercises with a wrist weight. By this point, left shoulder flexion was pain-free to 90 degrees in the
wall walk. Abduction, adduction and extension were also pain-free in the active range.
‡ Following visit 10, a therapeutic withdrawal from treatment began, with home instruction to continue pendulum exercises holding a soup
can, and wall walking to 90 degrees, using three sets of repetitions twice daily (following with cryotherapy at a 15-minute duration).
‡ The patient returned after a two-week withdrawal from treatment without repercussion or recrudescence of his condition.
‡ A re-evaluation of shoulder range of motion determined active flexion, 85/90; extension, 45/45; abduction, 170/180; adduction, 40/45;
internal rotation, 50/55; and external rotation, 40/45. The patient was provided with level 1 therabands and instructed in proper use. Home
exercise protocols consisted of flexion, extension, internal and external rotation, and vertical lifts at a frequency of three times per week,
using three sets of 10 repetitions, for three weeks. If he experienced an increase in symptoms or a loss of function, he was to discontinue
the exercises and contact the facility.
‡ Following three weeks of home protocols, the patient was again re-evaluated and remained asymptomatic, with full, unrestricted left
shoulder range of motion.
Figure 1 Posterior shoulder stretch. Figure
Stand 3 Shoulder Abduction. Stand with
with your your right side
back leaning against a wall. Hold the against a wall. Gently push your arm out
affected arm against the wall
straight out. Hold the back of theFigure
elbow
with4 25%
Shoulder lateral
of your rotation.
strength and Stand
hold the
and pull the arm withcontraction
your right for 3 s.
across the front of the body. Hold 30Repeat
side s then 5atimes.
against wall. Bend your increase
Gradually right arm to 3
relax. 901.sets
Gently push
of 5±10
the back
Figure 5 Shoulder extension. of your
withright hand out against the
repetitions.
Stand
Figure 2your back flexion. Standwall
Shoulder
with 25%
facing a
against a wall. Gently pushof your
yourstrength
arm and hold the contraction
wall. Gently
backwards for 3 s. Repeat 5
against against
push your arm out forwards the
times. Gradually increase to 3 sets of 5±10
wall withthe
25% wall
of with 25% of your strength and hold
repetitions.
the and hold the contraction
your strength for 3
contraction Figure 1 Posterior shoulder stretch. Stand
for 3 s. Repeat 5 times.
s. Repeat 5
Graduallyincrease with your
increaseto 3 sets
times. Gradually of 5±10
to 3 sets of 5 to 10 back leaning against a wall. Hold the
repetitions.
repetitions.
affected arm
straight out. Hold the back of the elbow
and pull the arm
across the front of the body. Hold 30 s then
relax.
 Conclusion
‡ Primary adhesive capsulitis, also known as
frozen shoulder, is characterized by an initial
course of generalized shoulder pain, followed by
a gradual nonpainful loss in shoulder range of
motion. As evident by this case study,
conservative methods (including passive
modalities) followed by transition to active
protocols, with a release to independent
exercise instruction, are valuable in promoting a
return to normal, nonpyhsician-dependent
function.
 Case Study #1
‡ A 23 year old comes to you complaining of
shoulder pain. He says that 2 days ago he
was playing catch with a football; when his
friend threw the ball, he reached for it
above his head, lost his balance, and fell
on an outstretched hand out to the side.
He felt the shoulder ³slip´ a little and then
pain. He complains of pain in his
upper/anterior shoulder and upper chest
region. Also reports a ³clicking´ sensation.
 Case Study #2
‡ A female competitive swimmer comes to
you complaining of diffuse shoulder pain.
She notices the problem most when she
does the butterfly. She complains that her
shoulder sometimes feels unstable and
weak when doing this stroke, she has
even felt it ³pop´ once. She reports some
changes in sensation along the outside of
her arm ± near her deltoid.
 Case Study #3
‡ A 30 year old tennis player complains of
pain throughout shoulder and into arm.
Notices increased episodes of hands
³falling asleep´ during the night. Also
notices that hands are often cold. Notices
that discomfort increases with overhead
serving and returns. Also, has problems in
the weight room and with ADLs when
arms are overhead.
 Case Study #4
‡ A major league baseball pitcher reports to
athletic training room with increasing pain
in shoulder on follow-through of pitching.
Pain increases when he has pitched more
than 70 pitches. He localizes pain to area
by greater tubercle. It is point tender and
slightly swollen. He has excessive external
rotation and limited internal rotation.
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