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During the clinical examination, the therapist will aim to determine (Lewis, 2015):
If the pain is not referred or in connection with other causes (cervical, thoracic, vascular, neurological) â
If there is no instability â
If it's not a stiff shoulder (this includes contractile capsule) â
If the pain comes from soft tissue â
Or a combination of all of these
The therapist will also have to exclude serious pathologies, consider the mechanisms Of production Of the pain while integrating the model biopsychosocial.
The diagnosis of shoulder pain and mobility deficits associated with primary or secondary capsulitis is determined based on anamnesis and physical examination (Kelley et al., 2013). It is important to note, however, that currently there is no No gold standard allowing the diagnosis of retractile capsulitis in the early phase (Walmsley et al., 2014).
b - Anamnesis
What are the elements during the anamnesis that will make us suspect a retractile capsule?
Generally, they are women between 40 and 65 years of age (Kelley et al., 2013). â
The patient is not always able to explain the beginning. In the case of primary capsulitis, it does not indicate having suffered trauma and the radiographs present point in the same direction (Srour & Nourissat, 2021). â
Pain can be poorly localized and described as deep pain, or sometimes occurs as pain referred to the distal insertion of the deltoid, radiating to the biceps area (Ramirez, 2019). According to a recent study, it seems that the most frequently painful area in capsulites is the anterolateral area of the shoulder (Balasch-Bernat et al., 2021) â
This pain is significantly increased during rapid and unprepared movements. In addition, it is increasing and gradually becomes nocturnal, especially at the beginning of symptoms. This nocturnal pain prevents the patient from sleeping on the shoulder, thus disrupting sleep (Date & Rahman, 2020; Kelley et al., 2013). Note that this sleep disturbance could lead to a psychological state that is unfavorable to a good recovery (Mulligan et al., 2015). â
The patient describes restrictions on anterior, lateral, and hand-in-back elevation movements (Srour & Nourissat, 2021). â
The involvement often occurs unilaterally and affects the non-dominant limb, although the dominant shoulder is affected in 30% of cases (Fields et al., 2019). However, it should be noted that in 40 to 50% of cases the attack exists bilaterally, but as mentioned above, rarely simultaneously (Manske & Prohaska, 2010).
Symptoms such as fever, night sweats, malaise, or unexplained weight loss are red flags and should prompt the therapist to consider an alternative diagnosis.
â
c - Clinical evaluation
From the beginning of the clinical examination, it is possible to suspect a capsule infection when the patient takes off his clothes. In fact, scars may be observed indicating trauma and/or surgery (secondary capsulitis of intrinsic/extrinsic origin) or when the patient has a marked atrophy of the shoulder, which may be a sign of a decrease in active mobility (Sumarwoto et al., 2021). We can already quite simply observe amplitude deficits when the patient is unable to perform the movements necessary to undress.
1 - Mobility
Assessing amplitudes is crucial in examining capsules (Sumarwoto et al., 2021). Indeed, this entity may be suspected when a global amplitude deficit movements exist (Kelley et al., 2013). According to the patient, the deficit has been going on for at least 1 month and it could reach a Plateau phase or would tend to get worse (Binder et al., 1984; Kelley et al., 2013; Robinson et al., 2012).
Concretely, all amplitudes (flexure, extension, rotation, abduction, adduction, etc.) should be evaluated in active and passive. In order to assess active mobility, the patient may be asked to perform an active elevation bilaterally, to carry both hands behind the neck, to place his hands behind his back or even to bring the hand as close as possible to the opposite shoulder (Srour & Nourissat, 2021). It should be noted that these functional amplitudes would generally be more diminished due to pain and/or stiffness (Kelley et al., 2013).
Regarding passive mobility, the therapist can use a goniometer or an inclinometer (De Baets, Matheve, Dierickx, et al., 2020). Some authors consider that it is more appropriate to assess internal and external rotation, abduction and elevation in the dorsal recumbency, given the bias that scapulothoracic movements can bring (Sumarwoto et al., 2021) although other authors suggest an evaluation sitting on a stool with the therapist fixing the scapula to the chest and performing the various movements of the glus joint gently (to avoid involuntary muscle contractions). humeral. Note that the movement can be performed until the pain stops the movement or until the maximum amplitude is reached.
Thus, for Codman, capsulitis could be suspected when a patient shows a decrease in external rotation with a normal x-ray (Marc et al., 2016). However, new studies show that a loss of amplitude greater than 25% In at least 2 plans And a loss of passive external rotation greater than 50% compared to the contralateral shoulder or a passive RE less than 30° (elbow to the body) have been used to define retractile capsule (Kelley et al., 2013). It should be noted that when the pain is recent and the amplitudes are not too limited, the restriction of lateral rotation elbow to the body (or in position RE1) greater than 50% with reference to the healthy side represents a sign specific to capsulitis (D'Orsi et al., 2012; 2012; Lewis, 2012; Lewis, 2012; Lewis, 2012; Lewis, 2015; Lewis, 2015; 2015; Mitsch et al., 2004) which would also be the most recognized by practitioners (Hanchard et al., 2011). Likewise, a decrease in lateral rotation can be observed when arm abduction increases (Srour & Nourissat, 2021).
It should be noted that according to some authors (Donatelli et al., 2014), external rotation should be tested with different degrees of abduction. In fact, if the external rotation is more limited to 45°, this could be correlated to a restriction mainly related to the subscapular muscle or to the glenohumeral ligament, while at 90°, the limitation would come mainly from the anterior capsule as well as from the inferior capsule ligament complex.
Finally, it seems interesting to note that all the endings of amplitudes are painful unlike other pathologies (Srour & Nourissat, 2021).
Note that the template capsular described by Cyriax in 1970 stipulating that the loss of external rotational movement is proportional to the loss of abduction, which is more limited than the internal rotation, is not systematically found (Kelley et al. 2013).
Finally, the evaluation of the patient's posture in the sagittal plane can be carried out since if this posture is not directly involved in the development of capsulitis, it could be involved in the loss of amplitude when the patient presents a kyphotic attitude (Donatelli et al., 2014).
2 - Specific tests
Although this is not a specific test, it should be noted that on palpation, tenderness is frequently found at the level of deltoid insertion (Sumarwoto et al., 2021).
With regard to specific tests, several tests have been described in order to identify a capsule:
The Shrug test: Seated patient is asked to perform a double bend of the elbows at 90°. Then, he performs a bilateral abduction of the shoulders up to 90° while keeping the elbows bent. The test is considered positive if the patient performs a shoulder lift (a shrug) in order to reach 90 degrees of abduction. This test would have a sensitivity of 95% and a specificity of 50% (Jia et al., 2008) â
The palpatory test (or sign of the coracoid process): While seated, the therapist performs a palpation of the acromial clavicular, the anterolateral region of the acromion and the coracoid process. In the case of pain, the therapist remembers the pain recorded by the patient on each palpation point. The test is considered positive when the pain felt in the coracoid process is 3 points greater than the pain felt on the acromioclavicular and the anterolateral side of the acromion (Carbone et al., 2010). According to these same authors, this test would have a sensitivity of 96% with a specificity of 87%, which in their opinion would make it a pathognomic sign (Carbone et al., 2010) even if it would be important for other studies to confirm these clinimetric properties.
Summary of the diagnosis of retractile capsulitis
d - Additional examinations:
Lab test results are generally normal but can be useful in identifying underlying conditions, such as diabetes or thyroid disease (Date & Rahman, 2020)
Simple shoulder X-rays are generally normal but can help diagnose or rule out other conditions, such as calcifying rotator cuff tendinopathy, glenohumeral arthritis, acromioclavicular arthritis, osteoporosis, osteoporosis, or even shoulder dislocation (Gordon et al., 2016, p. 201; Sumarwoto et al., 2021). It also makes it possible to measure the rise of the humeral head in favor of a rupture of the cuff as an alternative cause of the patient's shoulder pain (Buchard et al., 2017; Fields et al., 2019).
Regarding magnetic resonance imaging, the latter could be offered to patients with few clinical symptoms who may have been misdiagnosed (bursitis, rotator cuff, etc...) (Sumarwoto et al., 2021). On MRI, capsulitis would only be characterized by an edematous appearance of the joint as well as by the thickening of the axillary recess (Gokalp et al., 2011; Zhao et al., 2012). Note that there would be no consensus on the use of MRI (Harris et al., 2013).
For its part, ultrasound could have many benefits (Sumarwoto et al., 2021). Indeed, in addition to these usual advantages (low cost, quick to perform, etc.) it would allow the doctor to compare the results of the ultrasound to the clinical results. For example, increased blood flow and a decrease in rotator interval space are common signs when evaluating capsulitis (Sumarwoto et al., 2021). Likewise, a thickening of the coracohumeral ligament, characteristic of capsulitis, may be encountered.
Finally, some signs may be associated with a phase in the evolution of capsulitis. For example, the existence of a hypoechoic zone in the rotator interval coupled with increased vascularization could be associated with an early diagnosis of capsulitis (Harris et al., 2013; Walmsley et al., 2013; Walmsley et al., 2013). A second example is the one put forward previously where Fields and his collaborators were able to show a correlation between ultrasound observations and the various phases of capsulitis (Fields et al., 2019).
e - Differential diagnosis:
After addressing the clinical examination of âpureâ capsulitis, it is important to note that a painful shoulder with a reduced amplitude is a frequent phenomenon and not specific to capsulitis. Thus, it is essential to be able to eliminate other pathologies via clinical examination and complementary examinations (Sumarwoto et al., 2021).
In the search for other pathologies, pain in the forearm and/or hand could suggest other pathologies that may be of cervical origin, while an improvement in external rotation during arm abduction eliminates the probability that it is a capsule (Srour & Nourissat, 2021). Likewise, the onset of pain when carrying out so-called âoverheadâ activities would not be linked to retractile capsulitis (Sumarwoto et al., 2021).
In order to continue the approach, it is possible to rely on the latest summaries proposed by Srour and Nourissat (Srour & Nourissat, 2021). According to them, it is important to rule out red flags at first. On this subject, Mitchells and his collaborators (Mitchell et al., 2005) were able to list some red flags related to the shoulder:
Tumor: history of cancer, symptoms of cancer (weight loss, pain not related to mechanical stress, asthenia). â
Infection: skin redness, fever. â
Fracture: significant trauma, debilitating acute pain, loss of mobility, deformity, or loss of the classical contour of the bone. â
Neurological injury: unexplained motor and/or sensory deficit. â
Visceral pathology: pain not reproduced by shoulder loading, pain and/or symptoms accentuated by exercise and/or breathing, pain associated with gastrointestinal symptoms.
Thus, according to McClure and Michener (McClure & Michener, 2015), it is possible to establish some frequently encountered characteristics depending on the pathologies that will make it possible to put a chip in the therapist's ear:
Sub-acromial syndrome: it is characterized by a painful arc, muscle weakness (even atrophy), pain during isometric contraction, and impingement tests (Neer, Hawkins, Jobe's) that are generally positive. Conversely, there is generally no sign of instability or a significant loss of amplitude. â
Instability: age under 40, history of dislocation or subluxation, positive apprehension and reduction tests, generalized laxity. Conversely, in the absence of a history of dislocation and the absence of positivity on the apprehension tests, instability can be ruled out. â
Capsulitis: it is characterized as said above by progressive pain, a loss of amplitudes in different planes and in particular in external rotation elbow to the body as well as by pain at the end of its amplitude. Conversely, the absence of a reduction in amplitudes as well as an age of less than 40 years reduces the risk of being confronted with capsulitis. â
Other possible pathologies: post-operative pain, glenohumeral arthritis and/or osteoarthritis, fractures or injuries of the acromioclavicular joint, peripheral neurogenic syndrome or myofascial pain.
Returning to the approach proposed by Srour & Nourissat, the involvement of the cervical spine or the acromioclavicular joint should be evaluated. Then, a capsulitis may be suspected if there is a decrease in mobility and particularly in external rotation elbow to the body, if the pain is present in all amplitudes and if the coracoid process test is positive.
f - Follow-up evaluation
Once retractile capsulitis has been diagnosed, it will be important to detect the various risk factors that can negatively influence the patient's development during rehabilitation:
The yellow flags (individual, psychological, cognitive, behavioral risk factors), â
Blue flags (risk factors related to professional activity and its perception of health) â
Black flags (risk factors linked to the context and obstacles (legislative, insurance...).
--> The more yellow, blue, black flags the patient shows, the more difficult the evolution is likely to be.
However, let's remember that red flags and orange flags are exclusion criteria.
â
To assess these elements, the therapist can use a variety of key questions:
What do you think caused the problem? â
What do you think is going to happen to you now? â
How do you deal with your problem? â
When do you plan to go back to work? â
What could be done at work to improve the situation?
â
Once these flags have been investigated, various monitoring elements are important to take into account to guide rehabilitation and assess the effects of therapeutic interventions. Clinical guidelines recommend the use of objective measures of physical deficits combined with validated functional self-report scores (Kelley et al., 2013):
Measurements of active and passive amplitude are therefore generally combined with the results of shoulder stiffness perceived by the patient, the intensity of pain and self-reported shoulder function (De Baets, Matheve, Dierickx, et al., et al., 2020): it may be interesting to know the patient's perception of the stiffness of his shoulder during movement (De Baets, Matheve, Dierickx, et al., 2020): it may be interesting to know the patient's perception of the stiffness of his shoulder during movement (De Baets, Matheve, Dierickx, et al., 2020): it may be interesting to know the patient's perception of the stiffness of his shoulder during movement (De Baets, Matheve, Dierickx, et al., 2020): it may be interesting to know the patient's perception of the stiffness of his shoulder during movement et al., 2020). â
The therapist may use an 11-point numerical rating scale with 0 = no feeling of shoulder stiffness and 10 = the highest feeling of shoulder stiffness imaginable. It may be useful to ask the patient to note their perception of middle shoulder stiffness over the past week. â
The intensity of the pain will also be an essential point in monitoring the patient throughout rehabilitation. The therapist will be able to use the visual analog scale (EVA) to know the intensity of the patient's average shoulder pain over the past week, at rest, at night, and during activities of daily living (De Baets, Matheve, Dierickx, et al., 2020).
With regard to functional scores, the latest recommendations (Kelley et al., 2013) indicate, with a high level of evidence, that clinicians should use Validated scores such as:
âThe DASH : subjective questionnaire composed of 30 questions, the score ranges from 0 to 100 where 0 indicates the absence of pain and difficulties. Available in French, the minimal and significant clinical score would be between 6 and 12 points (10 on average). Advised by the HAS, it assesses the quality of life. Note that there is a shortened version, the quick DASH, which would present significant values and could be more useful in daily practice (Cordesse, 2014; Kelley et al., 2013) (6,7,15). â
âThe SPADI : this score is composed of 13 items. This is a self-questionnaire containing two areas: 5 questions about pain and 8 questions about related disabilities. The total score is 100 and this score is in proportion to the pain and difficulties experienced by the patient. The minimum clinical difference to be significant is 8 to 13 points depending on the references (Breckenridge & McAuley, 2011; Kelley et al., 2013). â
âTHE AESUS : Again, this is a patient self-assessment ranging from 0 to 100. This time, the score is proportional to the functionality of the shoulder. 50 points are awarded to pain and 50 points to functionality. The minimal and significant clinical difference would be 9 points (Kelley et al., 2013).
The use of these scores makes it possible, if they are carried out before and after physiotherapy sessions, to monitor the evolution of the patient's functional limitations. Also, therapists could use scores to complete âpsychologicalâ assessment of the patient and to possibly identify other yellow flags. Indeed, as discussed earlier, some factors could negatively influence perceived pain and disability (De Baets, Matheve, Traxler, et al., 2020). This is the case for example:
Catastrophism that could be evaluated by the PCS score (Pain Catastrophizing Scale) â
Kinesiophobia that could be evaluated by the score TSK (Tampa Scale of Kinesiophobia) (Tkachuk & Harris, 2012; Wheeler et al., 2019).
A 2018 systematic review pointed out that higher levels of catastrophism and kinesiophobia are significantly associated with greater pain intensity and disability in shoulder patients (Martinez-Calderon et al., 2018). A 2022 systematic review also reported that scores traditionally considered to assess physical dimensions such as shoulder pain, disability, and function seem to be influenced by psychological variables. In patients with retractile capsulitis, depression and anxiety have been associated with increased pain perception and decreased function and quality of life at baseline. Furthermore, fear and doom related to pain seem to be associated with the perception of arm function (Brindisino et al. 2022).
In general, the following table shows the various questionnaires that can be used in the evaluation of your patient's shoulder with for each questionnaire the factors measured.
g- Notion of irritability:
All the anamnesis, clinical assessment and scores will then make it possible to define the patient's level of irritability in order to guide and guide treatment throughout rehabilitation (Kelley et al., 2013; Vaillant, 2013; Vaillant, 2013).
A concept introduced in the 2000s by Maitland and other therapists (Kareha et al., 2021), it refers to the ability of tissues to tolerate physical stress (Mueller & Maluf, 2002) and is based in particular on the absence of correlation between the patho-anatomical diagnosis and the symptoms, disabilities and limitations perceived by the patient (Kareha et al., 2021). Moreover, irritability is likely to be linked to the physical state and the extent of the inflammatory activity present (Kelley et al., 2013).
In order to optimize the use of this concept of irritability, the âStaged Algorithm for Rehabilitation: Shoulder Disordersâ also called âStar-shoulderâ could be developed in the years 2015 (McClure & Michener, 2015). The latter is based on the principle that a physiotherapeutic diagnosis must be based on the concept of tissue irritability as well as on physical deficiencies in order to complete the patho-anatomical classification. In addition, the subject is in line with the latest guidelines developed on the subject (Kelley et al., 2013).
In use, this âStar-Shoulderâ is characterized by the classification of patients into three levels of irritability: high irritability, medium irritability and low irritability, which meet âspecific criteriaâ and which should be managed in a differentiated manner (McClure & Michener, 2015).
Thus, at the beginning of each session, the therapist can ask some key questions to determine the degree of irritability in which the patient is:
What is the pain level? (EVA) â
How is the pain at rest and at night? â
What are the functional impacts â
Does the pain appear before the movement is over or not?
Thanks to these questions, the therapist will be able to define what type of irritability he is facing:
The patient presenting with a high irritability, is more likely to report constant pain at night or at rest. The disability will be severe with actions that are quickly limited, such as raising the arm, which will often be incomplete. Likewise, the amplitudes of movements will frequently be more limited in active than in passive. â
The patient presenting with a moderate irritability For his part, he has pain that is often intermittent: sometimes he can sleep on his shoulder, sometimes it wakes him up: he is not constantly annoyed by the pain. If the pain limits him, he can generally perform the entire movement. â
The patient in a phase low irritability generally has very slight or even absent pain. It is possible to go further in the movement or even to add a slight overpressure at the end of the amplitude.
The issue of patient irritability is something that is used for capsulitis but also for other shoulder and body pathologies (Kareha et al., 2021). It is therefore important to assess the patient's level of irritability session after session in order to adapt the treatment (Kelley et al., 2013).
Regarding the clinimetry of this classification, studies have been able to show that it would have good inter-operator reliability although future studies are necessary for its final validation (Kareha et al., 2021)
In keeping with this notion of irritability, it will be important to determine At what point does a patient go from one phase of irritability to the next ? In order to answer this question, it is possible to determine certain elements on which to base ourselves. This is all the more important as this change in the level of irritability will determine the adjustments to be made in treatment.
Among the elements showing a decrease in irritability, we find:
An improvement in sleep and pain at night. This is the case, for example, of a patient, formerly in a phase of high irritability, testifying that he has recently been able to sleep little by little on his shoulder. â
A change in sensation in the limitation of movement. This is the case, for example, of a patient who, formerly in a phase of high irritability, felt acute pain, a burning sensation and heaviness in the shoulder when he moved his shoulder, although he has since experienced a decrease in these symptoms and the blockage is felt without too much pain.
It should be noted that very often, after the first physiotherapy session, patients feel an improvement while during the following sessions, they may have the impression that it is no longer progressing. This is linked to an evolution with plateau phases, with gradual improvements (Binder et al., 1984). Of course, you must warn them that it is normal for this to take time. Finally, it may be important to keep in mind that central awareness (SC), defined as an âamplification of neuronal signaling within the central nervous system (CNS) causing hypersensitivity to painâ (Woolf, 2011), may play a role in the onset of pain in patients suffering from retractile capsulitis. Moreover, the irritability model may not be suitable for patients with central sensitization (McClure & Michener, 2015).
The therapist who suspects central pain will adapt their treatment to reduce the patient's irritability and fear of movement (Sawyer et al., 2018). Pain neuroscience education may be an interesting approach for these patients. For example, the therapist can invite the patient to consult the siteâRetrain painâ which makes it possible to explain the different mechanisms of pain in a simplified way.
â
â
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During the clinical examination, the therapist will aim to determine (Lewis, 2015):
If the pain is not referred or in connection with other causes (cervical, thoracic, vascular, neurological)
If there is no instability
If it's not a stiff shoulder (this includes contractile capsule)
If the pain comes from soft tissue
Or a combination of all of these
The therapist will also have to exclude serious pathologies, consider the mechanisms Of production Of the pain while integrating the model biopsychosocial.
The diagnosis of shoulder pain and mobility deficits associated with primary or secondary capsulitis is determined based on anamnesis and physical examination (Kelley et al., 2013). It is important to note, however, that currently there is no No gold standard allowing the diagnosis of retractile capsulitis in the early phase (Walmsley et al., 2014).
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b - Anamnesis
What are the elements during the anamnesis that will make us suspect a retractile capsule?
Generally, they are women between 40 and 65 years of age (Kelley et al., 2013).
The patient is not always able to explain the beginning. In the case of primary capsulitis, it does not indicate having suffered trauma and the radiographs present point in the same direction (Srour & Nourissat, 2021).
Pain can be poorly localized and described as deep pain, or sometimes occurs as pain referred to the distal insertion of the deltoid, radiating to the biceps area (Ramirez, 2019). According to a recent study, it seems that the most frequently painful area in capsulites is the anterolateral area of the shoulder (Balasch-Bernat et al., 2021)
This pain is significantly increased during rapid and unprepared movements. In addition, it is increasing and gradually becomes nocturnal, especially at the beginning of symptoms. This nocturnal pain prevents the patient from sleeping on the shoulder, thus disrupting sleep (Date & Rahman, 2020; Kelley et al., 2013). Note that this sleep disturbance could lead to a psychological state that is unfavorable to a good recovery (Mulligan et al., 2015).
The patient describes restrictions on anterior, lateral, and hand-in-back elevation movements (Srour & Nourissat, 2021).
The involvement often occurs unilaterally and affects the non-dominant limb, although the dominant shoulder is affected in 30% of cases (Fields et al., 2019). However, it should be noted that in 40 to 50% of cases the attack exists bilaterally, but rarely simultaneously (Manske & Prohaska, 2010).
Symptoms such as fever, night sweats, malaise, or unexplained weight loss are red flags and should prompt the therapist to consider an alternative diagnosis.
â
c - Clinical evaluation
From the beginning of the clinical examination, it is possible to suspect a capsule infection when the patient takes off his clothes. In fact, scars may be observed indicating trauma and/or surgery (secondary capsulitis of intrinsic/extrinsic origin) or when the patient has a marked atrophy of the shoulder, which may be a sign of a decrease in active mobility (Sumarwoto et al., 2021). Or simply observe amplitude deficits when the patient is unable to perform the movements necessary to undress.
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1 - Mobility
Assessing amplitudes is crucial in examining capsules (Sumarwoto et al., 2021). Indeed, this entity may be suspected when a global amplitude deficit movements exist (Kelley et al., 2013). According to the patient, the deficit has been going on for at least 1 month and it could reach a Plateau phase or would tend to get worse (Binder et al., 1984; Kelley et al., 2013; Robinson et al., 2012).
Concretely, all amplitudes (flexure, extension, rotation, rotation, abduction, adduction, etc.) should be evaluated both actively and passively. In order to assess active mobility, the patient may be asked to perform an active elevation bilaterally, to carry both hands behind the neck, to place his hands behind his back or even to bring the hand as close as possible to the opposite shoulder (Srour & Nourissat, 2021). It should be noted that these functional amplitudes would generally be more diminished due to pain and/or stiffness (Kelley et al., 2013).
Regarding passive mobility, the therapist can use a goniometer or an inclinometer (De Baets, Matheve, Dierickx, et al., 2020). Some authors consider that it is more appropriate to assess internal and external rotation, abduction and elevation in the dorsal recumbency, given the bias that scapulothoracic movements can bring (Sumarwoto et al., 2021) although other authors suggest an evaluation sitting on a stool with the therapist fixing the scapula to the chest and performing the various movements of the glus joint gently (to avoid involuntary muscle contractions). humeral. Note that the movement can be performed until the pain stops the movement or until the maximum amplitude is reached.
Thus, for Codman, capsulitis could be suspected when a patient shows a decrease in external rotation with a normal x-ray (Marc et al., 2016). However, new studies show that a loss of amplitude greater than 25% In at least 2 plans And a loss of passive external rotation greater than 50% compared to the contralateral shoulder or a passive RE less than 30° (elbow to the body) have been used to define retractile capsule (Kelley et al., 2013). It should be noted that when the pain is recent and the amplitudes are not too limited, the restriction of lateral rotation elbow to the body (or in position RE1) greater than 50% with reference to the healthy side represents a sign specific to capsulitis (D'Orsi et al., 2012; 2012; Lewis, 2012; Lewis, 2012; Lewis, 2012; Lewis, 2015; Lewis, 2015; 2015; Mitsch et al., 2004) which would also be the most recognized by practitioners (Hanchard et al., 2011). Likewise, a decrease in lateral rotation can be observed when arm abduction increases (Srour & Nourissat, 2021).
It should be noted that according to some authors (Donatelli et al., 2014), external rotation should be tested with different degrees of abduction. In fact, if the external rotation is more limited to 45°, this could be correlated to a restriction mainly related to the subscapular muscle or to the glenohumeral ligament, while at 90°, the limitation would come mainly from the anterior capsule as well as from the inferior capsule ligament complex.
Finally, it seems interesting to note that all the endings of amplitudes are painful unlike other pathologies (Srour & Nourissat, 2021).
Note that the template capsular described by Cyriax in 1970 stipulating that the loss of external rotational movement is proportional to the loss of abduction, which is more limited than the internal rotation, is not systematically found (Kelley et al. 2013).
Finally, the evaluation of the patient's posture in the sagittal plane can be carried out since if this posture is not directly involved in the development of capsulitis, it could be involved in the loss of amplitude when the patient presents a kyphotic attitude (Donatelli et al., 2014).
2 - Specific tests
Although this is not a specific test, it should be noted that on palpation, tenderness is frequently found at the level of deltoid insertion (Sumarwoto et al., 2021).
With regard to specific tests, several tests have been described in order to identify a capsule:
The Shrug test: Seated patient is asked to perform a double bend of the elbows at 90°. Then, he performs a bilateral abduction of the shoulders up to 90° while keeping the elbows bent. The test is considered positive if the patient performs a shoulder lift (a shrug) in order to reach 90 degrees of abduction. This test would have a sensitivity of 95% and a specificity of 50% (Jia et al., 2008)
The palpatory test (or sign of the coracoid process): While seated, the therapist performs a palpation of the acromial clavicular, the anterolateral region of the acromion and the coracoid process. In the case of pain, the therapist remembers the pain recorded by the patient on each palpation point. The test is considered positive when the pain felt in the coracoid process is 3 points greater than the pain felt on the acromioclavicular and the anterolateral side of the acromion (Carbone et al., 2010). According to these same authors, this test would have a sensitivity of 96% with a specificity of 87%, which in their opinion would make it a pathognomic sign (Carbone et al., 2010) even if it would be important for other studies to confirm these clinimetric properties.
â
d - Additional examinations:
Lab test results are generally normal but can be useful in identifying underlying conditions, such as diabetes or thyroid disease (Date & Rahman, 2020)
Simple shoulder X-rays are generally normal but can help diagnose or rule out other conditions, such as calcifying rotator cuff tendinopathy, glenohumeral arthritis, acromioclavicular arthritis, osteoporosis, osteoporosis, or even shoulder dislocation (Gordon et al., 2016, p. 201; Sumarwoto et al., 2021). It also makes it possible to measure the rise of the humeral head in favor of a rupture of the cuff as an alternative cause of the patient's shoulder pain (Buchard et al., 2017; Fields et al., 2019).
Regarding magnetic resonance imaging, the latter could be offered to patients with few clinical symptoms who may have been misdiagnosed (bursitis, rotator cuff, etc...) (Sumarwoto et al., 2021). On MRI, capsulitis would only be characterized by an edematous appearance of the joint as well as by the thickening of the axillary recess (Gokalp et al., 2011; Zhao et al., 2012). Note that there would be no consensus on the use of MRI (Harris et al., 2013).
For its part, ultrasound could have many benefits (Sumarwoto et al., 2021). Indeed, in addition to these usual advantages (low cost, quick to perform, etc.) it would allow the doctor to compare the results of the ultrasound to the clinical results. For example, increased blood flow and a decrease in rotator interval space are common signs when evaluating capsulitis (Sumarwoto et al., 2021). Likewise, a thickening of the coracohumeral ligament, characteristic of capsulitis, may be encountered.
Finally, some signs may be associated with a phase in the evolution of capsulitis. For example, the existence of a hypoechoic zone in the rotator interval coupled with increased vascularization could be associated with an early diagnosis of capsulitis (Harris et al., 2013; Walmsley et al., 2013; Walmsley et al., 2013). A second example is the one put forward previously where Fields and his collaborators were able to show a correlation between ultrasound observations and the various phases of capsulitis (Fields et al., 2019).
e - Differential diagnosis:
After addressing the clinical examination of âpureâ capsulitis, it is important to note that a painful shoulder with a reduced amplitude is a frequent phenomenon and not specific to capsulitis. Thus, it is essential to be able to eliminate other pathologies via clinical examination and complementary examinations (Sumarwoto et al., 2021).
In the search for other pathologies, pain in the forearm and/or hand could suggest other pathologies that may be of cervical origin, while an improvement in external rotation during arm abduction eliminates the probability that it is a capsule (Srour & Nourissat, 2021). Likewise, the onset of pain when carrying out so-called âoverheadâ activities would not be linked to retractile capsulitis (Sumarwoto et al., 2021).
In order to continue the approach, it is possible to rely on the latest summaries proposed by Srour and Nourissat (Srour & Nourissat, 2021). According to them, it is important to rule out red flags at first. On this subject, Mitchells and his collaborators (Mitchell et al., 2005) were able to list some red flags related to the shoulder:
Tumor: history of cancer, symptoms of cancer (weight loss, pain not related to mechanical stress, asthenia).
Infection: skin redness, fever.
Fracture: significant trauma, debilitating acute pain, loss of mobility, deformity, or loss of the classic bone contour.
Neurological injury: unexplained motor and/or sensory deficit.
Visceral pathology: pain not reproduced by shoulder loading, pain and/or symptoms accentuated by exercise and/or breathing, pain associated with gastrointestinal symptoms.
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Thus, according to McClure and Michener (McClure & Michener, 2015), it is possible to establish some frequently encountered characteristics depending on the pathologies that will make it possible to put a chip in the therapist's ear:
Sub-acromial syndrome: it is characterized by a painful arc, muscle weakness (even atrophy), pain during isometric contraction, and impingement tests (Neer, Hawkins, Jobe's) that are generally positive. Conversely, there is generally no sign of instability or a significant loss of amplitude.
Instability: age under 40, history of dislocation or subluxation, positive apprehension and reduction tests, generalized laxity. Conversely, in the absence of a history of dislocation and the absence of positivity on the apprehension tests, instability can be ruled out.
Capsulitis: it is characterized as said above by progressive pain, a loss of amplitudes in different planes and in particular in external rotation elbow to the body as well as by pain at the end of its amplitude. Conversely, the absence of a reduction in amplitudes as well as an age of less than 40 years reduces the risk of being confronted with capsulitis.
Other possible pathologies: post-operative pain, glenohumeral arthritis and/or osteoarthritis, fractures or injuries of the acromioclavicular joint, peripheral neurogenic syndrome or myofascial pain.
Returning to the approach proposed by Srour & Nourissat, the involvement of the cervical spine or the acromioclavicular joint should be evaluated. Then, a capsulitis may be suspected if there is a decrease in mobility and particularly in external rotation elbow to the body, if the pain is present in all amplitudes and if the coracoid process test is positive.
f - Follow-up evaluation
Once retractile capsulitis has been diagnosed, it will be important to detect the various risk factors that can negatively influence the patient's development during rehabilitation:
The yellow flags (individual, psychological, cognitive, behavioral risk factors),
Blue flags (risk factors related to professional activity and its perception of health)
Black flags (risk factors linked to the context and obstacles (legislative, insurance...).
--> The more yellow, blue, black flags the patient shows, the more difficult the evolution is likely to be.
However, let's remember that red flags and orange flags are exclusion criteria.
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To assess these elements, the therapist can use a variety of key questions:
What do you think caused the problem?
What do you think is going to happen to you now?
How do you deal with your problem?
When do you plan to go back to work?
What could be done at work to improve the situation?
â
Once these flags have been investigated, various monitoring elements are important to take into account to guide rehabilitation and assess the effects of therapeutic interventions. Clinical guidelines recommend the use of objective measures of physical deficits combined with validated functional self-report scores (Kelley et al., 2013):
Measurements of active and passive amplitude are therefore generally combined with the results of shoulder stiffness perceived by the patient, the intensity of pain and self-reported shoulder function (De Baets, Matheve, Dierickx, et al., et al., 2020): it may be interesting to know the patient's perception of the stiffness of his shoulder during movement (De Baets, Matheve, Dierickx, et al., 2020): it may be interesting to know the patient's perception of the stiffness of his shoulder during movement (De Baets, Matheve, Dierickx, et al., 2020): it may be interesting to know the patient's perception of the stiffness of his shoulder during movement (De Baets, Matheve, Dierickx, et al., 2020): it may be interesting to know the patient's perception of the stiffness of his shoulder during movement et al., 2020).
The therapist may use an 11-point numerical rating scale with 0 = no feeling of shoulder stiffness and 10 = the highest feeling of shoulder stiffness imaginable. It may be useful to ask the patient to note their perception of middle shoulder stiffness over the past week.
The intensity of the pain will also be an essential point in monitoring the patient throughout rehabilitation. The therapist will be able to use the visual analog scale (EVA) to know the intensity of the patient's average shoulder pain over the past week, at rest, at night, and during activities of daily living (De Baets, Matheve, Dierickx, et al., 2020).
With regard to functional scores, the latest recommendations (Kelley et al., 2013) indicate, with a high level of evidence, that clinicians should use Validated scores such as:
âThe DASH : subjective questionnaire composed of 30 questions, the score ranges from 0 to 100 where 0 indicates the absence of pain and difficulties. Available in French, the minimal and significant clinical score would be between 6 and 12 points (10 on average). Advised by the HAS, it assesses the quality of life. Note that there is a shortened version, the quick DASH, which would present significant values and could be more useful in daily practice (Cordesse, 2014; Kelley et al., 2013) (6,7,15).
âThe SPADI : this score is composed of 13 items. This is a self-questionnaire containing two areas: 5 questions about pain and 8 questions about related disabilities. The total score is 100 and this score is in proportion to the pain and difficulties experienced by the patient. The minimum clinical difference to be significant is 8 to 13 points depending on the references (Breckenridge & McAuley, 2011; Kelley et al., 2013).
âTHE AESUS : Again, this is a patient self-assessment ranging from 0 to 100. This time, the score is proportional to the functionality of the shoulder. 50 points are awarded to pain and 50 points to functionality. The minimal and significant clinical difference would be 9 points (Kelley et al., 2013).
The use of these scores makes it possible, if they are carried out before and after physiotherapy sessions, to monitor the evolution of the patient's functional limitations. Also, therapists could use scores to complete âpsychologicalâ assessment of the patient and to possibly identify other yellow flags. Indeed, as discussed earlier, some factors could negatively influence perceived pain and disability (De Baets, Matheve, Traxler, et al., 2020). This is the case for example:
Catastrophism that could be evaluated by the PCS score (Pain Catastrophizing Scale)
Kinesiophobia that could be evaluated by the score TSK (Tampa Scale of Kinesiophobia) (Tkachuk & Harris, 2012; Wheeler et al., 2019).
A 2018 systematic review pointed out that higher levels of catastrophism and kinesiophobia are significantly associated with greater pain intensity and disability in shoulder patients (Martinez-Calderon et al., 2018).
In general, the following table shows the various questionnaires that can be used in the evaluation of your patient's shoulder with for each questionnaire the factors measured.
â
g- Notion of irritability:
All the anamnesis, clinical assessment and scores will then make it possible to define the patient's level of irritability in order to guide and guide treatment throughout rehabilitation (Kelley et al., 2013; Vaillant, 2013; Vaillant, 2013).
A concept introduced in the 2000s by Maitland and other therapists (Kareha et al., 2021), it refers to the ability of tissues to tolerate physical stress (Mueller & Maluf, 2002) and is based in particular on the absence of correlation between the patho-anatomical diagnosis and the symptoms, disabilities and limitations perceived by the patient (Kareha et al., 2021). Moreover, irritability is likely to be linked to the physical state and the extent of the inflammatory activity present (Kelley et al., 2013).
In order to optimize the use of this concept of irritability, the âStaged Algorithm for Rehabilitation: Shoulder Disordersâ also called âStar-shoulderâ could be developed in the years 2015 (McClure & Michener, 2015). The latter is based on the principle that a physiotherapeutic diagnosis must be based on the concept of tissue irritability as well as on physical deficiencies in order to complete the patho-anatomical classification. In addition, the subject is in line with the latest guidelines developed on the subject (Kelley et al., 2013).
In use, this âStar-Shoulderâ is characterized by the classification of patients into three levels of irritability: high irritability, medium irritability and low irritability, which meet âspecific criteriaâ and which should be managed in a differentiated manner (McClure & Michener, 2015).
Thus, at the beginning of each session, the therapist can ask some key questions to determine the degree of irritability in which the patient is:
What is the pain level? (EVA)
How is the pain at rest and at night?
What are the functional impacts
Does the pain appear before the movement is over or not?
Thanks to these questions, the therapist will be able to define what type of irritability he is facing:
The patient presenting with a high irritability, is more likely to report constant pain at night or at rest. The disability will be severe with actions that are quickly limited, such as raising the arm, which will often be incomplete. Likewise, the amplitudes of movements will frequently be more limited in active than in passive.
The patient presenting with a moderate irritability For his part, he has pain that is often intermittent: sometimes he can sleep on his shoulder, sometimes it wakes him up: he is not constantly annoyed by the pain. If the pain limits him, he can generally perform the entire movement.
The patient in a phase low irritability generally has very slight or even absent pain. It is possible to go further in the movement or even to add a slight overpressure at the end of the amplitude.
The issue of patient irritability is something that is used for capsulitis but also for other shoulder and body pathologies (Kareha et al., 2021). It is therefore important to assess the patient's level of irritability session after session in order to adapt the treatment (Kelley et al., 2013).
Regarding the clinimetry of this classification, studies have been able to show that it would have good inter-operator reliability although future studies are necessary for its final validation (Kareha et al., 2021)
In keeping with this notion of irritability, it will be important to determine At what point does a patient go from one phase of irritability to the next ? In order to answer this question, it is possible to determine certain elements on which to base ourselves. This is all the more important as this change in the level of irritability will determine the adjustments to be made in treatment.
Among the elements showing a decrease in irritability, we find:
An improvement in sleep and pain at night. This is the case, for example, of a patient, formerly in a phase of high irritability, testifying that he has recently been able to sleep little by little on his shoulder.
A change in sensation in the limitation of movement. This is the case, for example, of a patient who, formerly in a phase of high irritability, felt acute pain, a burning sensation and heaviness in the shoulder when he moved his shoulder, although he has since experienced a decrease in these symptoms and the blockage is felt without too much pain.
It should be noted that very often, after the first physiotherapy session, patients feel an improvement while during the following sessions, they may have the impression that it is no longer progressing. This is linked to an evolution with plateau phases, with gradual improvements (Binder et al., 1984). Of course, you must warn them that it is normal for this to take time. Finally, it may be important to keep in mind that central awareness (SC), defined as an âamplification of neuronal signaling within the central nervous system (CNS) causing hypersensitivity to painâ (Woolf, 2011), may play a role in the onset of pain in patients suffering from retractile capsulitis. Moreover, the irritability model may not be suitable for patients with central sensitization (McClure & Michener, 2015).
The therapist who suspects central pain will adapt their treatment to reduce the patient's irritability and fear of movement (Sawyer et al., 2018). Pain neuroscience education may be an interesting approach for these patients. For example, the therapist can invite the patient to consult the siteâRetrain painâ which makes it possible to explain the different mechanisms of pain in a simplified way.
â
Video: summary of the diagnosis of retractile capsulitis
â
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