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Note: Find examples of treatments in videos based on the irritability of the patient at the bottom of this page
A - Prognosis
In general, one should not expect to have changes in the patient every 2 weeks, it is a pathology that takes time (Reeves et al. 1975). In fact, although retractile capsulitis generally occurs as a pathology resolutive (Hubbard et al. 2018; Xia et al. 2017), it can sometimes last up to 2 or 3 years or even never disappear completely (Zuckerman et al. 2011) with limited amplitudes as well as long-term pain (Le et al., 2017; 2017; Lewis, 2017; Lewis, 2017; Lewis, 2015; Manske & Prohaska, 2010; Wong et al., 2017). Factors with a âpoorâ prognosis include: diabetes, male sex or bilateral involvement. On the other hand, the duration of symptoms during the first visit does not seem to be linked to a poor prognosis (D. H. Kim et al., 2020). By focusing on diabetes, it is interesting to note that preliminary studies have been able to show that the prognosis may be poorer for people with diabetes (Dyer et al., 2021), which would correlate with previous studies that may have shown the frequent need to use other types of treatments (arthroscopies, etc.) following an inconclusive conservative treatment in diabetic patients (D. H. Kim et al. 2020; Rill et al., 2011). However, these cases would be the least frequent since conservative treatment would be effective in 90% of cases (Pandey & Madi, 2021)
b - General care recommendations
Although retractile capsulitis is a studied pathology, it is always curious to discover in the literature so many hypotheses and contradictions concerning the treatment of this pathology. Especially since it is a frequent, disabling pathology causing significant absenteeism at work.
In fact, empirical evidence suggests that some physiotherapy techniques and modalities are highly recommended for pain relief, improvement of range of motion, and functional status in patients with retractile capsule, while others are moderately or mildly recommended (Nakandala et al., 2021).
Thus, it is commonly accepted that the care Non-surgical, or conservative, should be the most appropriate treatment choice: most patients generally improve in 6 to 18 months (Georgiannos et al., 2017). In the absence of consensus on the best conservative therapeutic intervention, it is preferable to combine different treatment modalities (Page, Green, Kramer, Johnston, McBain, Chau, et al., 2014; Pandey & Madi, 2021) in order to adapt to the patient (Le et al., 2017).
Among the most recommended conservative treatments, we find physiotherapy through various active and passive treatments (Cho et al., 2019; Georgiannos et al., 2017; Kelley et al., 2013; Pandey & Madi, 2021; Rangan et al., 2015, 2016; Rangan et al., 2015, 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016 al., 2017; Pandey & Madi, 2021; Rangan et al., 2015, 2016; Vaishya et al., 2016; Yip et al., 2018) or the infiltrations (Cho et al., 2019; Georgiannos et al., 2019; Georgiannos et al., 2017; Georgiannos et al., 2017; Kelley et al., 2013; Pandey & Madi, 2021; Rangan et al., 2015, 2015; Vaishya et al., 2016; Yip et al., 2018).
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c - Medical treatments
With regard to medical treatment, numerous treatments have been proposed such as taking anti-inflammatories, injecting corticoids, manipulations under anesthesia, arthrolysis, etc...
1 - Oral medications
Taking anti-inflammatory drugs is frequently prescribed in the early stages of capsulitis in order to obtain a short-term reduction in pain (D'Orsi et al., 2012; Sumarwoto et al., 2021; Vaishya et al., 2016) by focusing on synovitis (Le et al., 2017). This intake could be considered for 2-3 weeks with the aim of allowing the patient to carry out their daily activities and physiotherapy more easily (Pandey & Madi, 2021) although these drugs do not have an impact on the natural evolution of capsulitis (Cho et al., 2019).
Taking corticosteroids could have effects on pain (and in particular nocturnal pain) as well as on short-term joint range (Sumarwoto et al., 2021; Yip et al., 2018) in the âfreezingâ or âfrozenâ phases where inflammation persists (Pandey & Madi, 2021). Oral steroids could have positive effects on pain and range of motion in the short term despite the risk of side effects (Pandey & Madi, 2021).
Of course, these treatments must be carried out in conjunction with a physiotherapeutic treatment of the âmanual therapyâ type (Page, Green, Kramer, Johnston, McBain, Chau, et al., 2014).
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A randomized controlled trial comparing oral corticosteroids and exercises in the treatment of retractile capsulitis. Both groups improved with superior results in terms of external rotation and abduction in the exercise group and side effects in the anti-inflammatory group, even at low doses.
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2 - Bee venom acupuncture
Described as a grade A therapy in the rehabilitation of capsulitis (Nakandala et al., 2021), acupuncture with bee venom could present interesting effects. Indeed, according to Koh and his collaborators, bee venom acupuncture (AVA) combined with physiotherapy treatment over a follow-up period of 12 weeks would have superior effects compared to a group that simply followed a physiotherapy treatment (composed of TENS, thermotherapy and manual therapy) (Koh et al., 2013). The reported effectiveness in reducing pain and improving function was re-evaluated retrospectively 1 year later by Park and her team. The authors found that the effects remained clinically effective 1 year after treatment and may contribute to improved long-term quality of life for patients with retractile capsulitis (Park et al., 2014).
While this technique could be interesting, there is however little scientific evidence concerning the use of this technique in daily practice for primary capsules (Rangan et al., 2016). In addition, although it is often described in âphysiotherapyâ treatments, it is still essential to remember that injecting products through the skin barrier is not part of the physiotherapist's field of expertise. Thus, unlike dry puncture (or âDry Needlingâ), this acupuncture with bee venom would therefore not be the responsibility of physiotherapists.
3 - Infiltrations
Intra-articular injection of corticosteroids by means of an infiltration would allow a rapid improvement in pain and joint amplitudes in the short (Srour & Nourissat, 2021) and medium term (Pandey & Madi, 2021) by suppressing the inflammatory response, and therefore, by extension, by limiting the differentiation of fibroblasts into myofibroblasts (Hettrich et al., 2021) by suppressing the inflammatory response, and therefore, by extension, by limiting the differentiation of fibroblasts into myofibroblasts (Hettrich et al., 2016).
In terms of effectiveness, combining infiltrations with mobility and stretching exercises would be more effective in the short term than exercises performed in isolation (Kelley et al., 2013). In addition, some authors show that injections would be more effective than oral corticosteroids (Le et al., 2017; Lorbach et al., 2010), while others consider that these injections would slow or even stop the progression of this pathology (Hettrich et al., 2016). In the long term, there would be no differences in effectiveness with physiotherapy treatment, oral corticosteroids and/or anti-inflammatories (Yip et al., 2018) even though some authors consider that infiltration would probably be one of the best current treatments for capsulitis (Challoumas et al., 2020).
Concretely, the technique consists in injecting Triamcinolone or Methylprednisolone into the shoulder (intra-articularly or in the rotator interval or in the sub-acromial space) noting that none of the injection sites seems superior to another. On the other hand, it seems that triamcinolone has effects that are sometimes greater than those of methylprednisolone and that the infiltration should be carried out all at once (Pandey & Madi, 2021). These infiltrations could be associated with manipulations as shown by some authors (Y. Zhang et al., 2022). In addition, a low dose of corticosteroids with a self-rehabilitation program would be more effective than a large dose of corticosteroids without a self-rehabilitation program (Minns Lowe et al., 2019). It is also interesting to note that at most the corticosteroid injection is Administered early in the process of pathology, the greater the effect on clinical symptoms. Corticosteroids may suppress the inflammatory response, but they cannot reverse fibrotic changes later in the cascade. When administered later in the stiffness stage, the effect of corticosteroids is generally more temporary (Ahn et al., 2018).
Note that this technique should be avoided for people with uncontrolled diabetes. Likewise, some minor side effects may occur such as: flushing, chest or shoulder pain, dizziness or nausea (Pandey & Madi, 2021).
Finally, while we have mainly addressed corticosteroid infiltrations, it seems important to emphasize that new systematic reviews show the effectiveness of hyaluronic acid infiltration into capsulitis in improving pain and joint amplitudes (Mao et al., 2022).
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4 - Arthrodilation (or Hydrodilation)
Technique used since the 1960s to treat capsulitis (Cho et al., 2019), it is often associated with infiltrations, the effectiveness of this technique has long been questioned (D'Orsi et al., 2012; Yip et al., 2018) although recent studies seem to show the effectiveness of hydrodilation combined with infiltration compared to an infiltration carried out alone (Challoumas et al., 2020; Yip et al., 2018) although recent studies seem to show the effectiveness of hydrodilation combined with infiltration in comparison to an infiltration carried out alone (Challoumas et al., 2020; Yip et al., 2018) although recent studies seem to show the effectiveness of hydrodilation combined with infiltration in comparison to an infiltration carried out alone (Challoumas et al., 2020; Yip et al., 2018) although recent studies seem to show the effectiveness of hydrodilation combined 2021).
In practice, the technique consists in injecting air or liquid into the capsule in order to stretch the capsule and allow an increase in the capsule volume. This technique is performed under fluoroscopy (Le et al., 2017). On the other hand, it could not be established whether capsule rupture should be achieved or if only capsule distension is necessary (Cho et al., 2019)
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5 - Manipulation under anesthesia
This technique consists in manipulating the capsule ligament complex on the patient's shoulder when the patient is under general anesthesia or inter-scalenic block. Concretely, once under anesthesia, the patient's shoulder is brought into flexure, abduction followed by external and/or internal rotations with arms at 90° abduction in order to stretch the retracted tissue (Pandey & Madi, 2021).
This manipulation is generally proposed in case of failure of conservative treatment lasting at least 6 months (Srour & Nourissat, 2021). In addition, offering this technique between 6 and 9 months after the onset of symptoms could be the most appropriate since an early implementation of this technique in the more âacuteâ phase could lead to a worsening of the symptoms (VastamĂ€ki et al., 2015). Regarding the technique, it should not necessarily be accompanied by infiltration although some practitioners appreciate this complementarity. In addition, it would present more moderate results in diabetic patients (Pandey & Madi, 2021).
This technique would have positive effects on improving pain, mobility function as well as on patient satisfaction (Kraal et al., 2019).
However, it should be noted that manipulation under anesthesia must be followed by physiotherapy in order to ensure the maintenance of the gains obtained (Srour & Nourissat, 2021).
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6 - Arthrolysis
The last âmedicalâ technique discussed, arthrolysis under arthroscopy seems effective in improving pain and mobility in patients in the short, medium and long term (Gleyze et al., 2011) while allowing the surgeon to obtain a direct view of the joint and to correct associated lesions (labrum, etc...) (Pandey & Madi, 2021). In the same way as for manipulation under anesthesia, the latter should only be considered in case of failure of conservative treatment after 6 months.
Regarding the duality between manipulation under anesthesia and arthrolysis, it seems that arthrolysis would present less risk of complications than mobilization under anesthesia with good results in diabetic patients (Ăınar et al., 2010; Grant et al., 2013). Note that no study can prove the superiority of one technique over the other (Pandey & Madi, 2021; Yip et al., 2018). On the other hand, the decision to perform arthrolysis would most often depend on the patient. Indeed, while the majority of capsulites resolve with conservative treatment within 1-2 years, some patients with a high level of activity prefer arthrolysis in order to accelerate recovery (Gordon et al., 2016).
In some cases, arthrolysis may be performed through open surgery when arthrolysis under arthroscopy is not able to improve joint pain or range of motion. In this case, a release of the coracohumeral ligament and the rotator interval is performed in order to obtain an improvement in joint range and pain (Le et al., 2017).
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d - Physiotherapy treatment
After having discussed the medical treatment that can be offered in retractile capsule, it is now time to focus on physiotherapeutic treatments. However, before detailing the various applicable modalities, it seems appropriate to first focus on the main recommendations and then to review the âirritabilityâ model as described by McClure in 2015 (McClure & Michener, 2015).
When we refer to the guidelines published by the APTA in 2013, it seems that rehabilitation should include therapeutic education, mobilizations and manipulations, stretching as well as other tools such as diathermy or electrotherapy (Kelley et al., 2013).
Despite all these studies, it still seems difficult to sort out the best treatments since most of the studies carried out so far are of low methodological quality or have different methods. It is therefore not easy to compare treatments with each other (Minns Lowe et al., 2019; Yip et al., 2018).
In this regard, some authors have suggested that among physiotherapy modalities, shock waves, stretching and laser therapy may represent the most recommended therapies in 2021 (Nakandala et al., 2021).
Consequently, it is therefore important to rely on another point of interest in rehabilitation: the concept of irritability.
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2 - Irritability and rehabilitation
As mentioned earlier, irritability is a key point in choosing the techniques to be addressed. Widely acclaimed by many authors (Cools, 2020; Lewis, 2015), it will aim to adapt treatment according to tissue irritability. Thus, if the patient has a profile that can be assimilated to the category âhigh irritabilityâ, âmedium irritabilityâ or âlow irritabilityâ, the treatment objectives will be adapted to the latter:
In high irritability: minimize physical stress, modify activities, and monitor for deficiencies. â
In moderate irritability: propose moderate physical stress, treat deficiencies and restore basic functional activities. â
In low irritability: propose high physical stresses, treat deficiencies and restore complex functional activities.
In order to facilitate clinical reasoning, it may be interesting at the beginning of the session to ask yourself the right questions as proposed in the study by Kareha and her collaborators (Kareha et al., 2021):
Thus, depending on the answers to these questions, it may be possible to quickly establish session goals with the appropriate tools.
By following this logic of irritability, it is once again possible to approach the recommendations for the management of retractile capsule proposed by the APTA in 2013 (Kelley et al., 2013, p. 20). This document was then based on literature from the 20th century up to 2011 in order to establish which techniques were of real interest in order to meet the rehabilitation objectives set in the context of the management of retractile capsule of the shoulder.
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3 - Therapeutic means
After having discussed the techniques proposed in 2013 by APTA and having previously shown that many methods have been able to demonstrate their effectiveness, it is now time to discuss the different treatment modalities. Of course, it will be necessary to integrate the concept of irritability in order to understand the treatment as a whole.
We will therefore first discuss the most widely recommended treatments such as therapeutic education, manual therapy, exercises or stretching before looking at other possible treatments such as thermotherapy, cryotherapy, acupuncture, acupuncture, acupuncture, acupuncture, electrotherapy, electrotherapy, electrotherapy, electrotherapy, electrotherapy, shock waves, ultrasound, diathermy, etc.
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Therapeutic education
Since 2013, all experts agree in recommending that clinicians conduct therapeutic education (Kelley et al., 2013). An essential point of treatment, it should therefore be implemented early and should allow (Kelley et al., 2013; Rangan et al., 2016):
To understand what a capsule is (an âinflammation of the capsule evolving into fibrosisâ), its benign nature and its evolution (not to mention that it is better to avoid talking about a âself-limitingâ pathology). â
To explain the different therapeutic options and their effectiveness in order to co-construct the ideal treatment. â
To explain the importance of the patient's adherence to treatment by insisting on the importance of carrying out the exercises independently (self-stretching, etc.)
This education will therefore make it possible to promote patient adherence and participation by avoiding âpassiveâ patients waiting for spontaneous resolution.
Also, it will be important to promote the modification of activities in order to carry out painless activities in a maximum range of activities. Likewise, it is essential for the patient to understand that he must adapt the intensity of the stretching (or treatment) to his stage of irritability (Kelley et al., 2013).
To go further in patient education, it should be noted that some studies suggest integrating pain education by explaining to the patient that pain comes from the brain, that it is not always associated with tissue damage, that the environment can influence the intensity of perceived pain, and that persistent pain can increase sensitivity to it (Sawyer et al., 2018).
Likewise, the identification of psychosocial factors revealed by questionnaires such as the âCastrophism Scal Breadâ Or the âTampa Scale of Kinesiophobiaâ for example, may encourage the therapist to employ specific patient education strategies in order to optimize the beneficial effects of interventions.
In 2015, Jeremy Lewis spoke of an essential first step in patient education. The therapist should be able to answer the patient's various questions, namely:
What do I have? â
What is the cause of the problem? â
How long is this going to last? â
What is the prognosis? â
What treatments are offered? â
What are the expected results?
Note that 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.
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Manual therapy
Manual therapy, in the context of retractile capsulitis, could be similar to âmanual techniquesâ applied to the patient's shoulder. The latter include simple passive mobilizations, manipulations, but also mobilizations resulting from different currents of thought such as techniques from Mulligan, Kaltenborn or Maitland for example.
When we look at the scientific evidence for manual therapy, it seems that:
Simple joint mobilizations combined with stretching allow an improvement in the amplitude of external rotation and abduction while improving functional scores at 1 year compared to stretching alone (Ăelik & Kaya Mutlu, 2016). On the other hand, these results were not found by Khan and his collaborators when they compared the mobilizations with exercises to exercises carried out in isolation (Khan, 2015). â
Mulligan techniques are effective in reducing pain and restoring range of motion and shoulder function when compared to a treatment consisting of heat therapy, electrotherapy, and passive stretching exercises (Doner et al., 2013). â
Techniques such as muscle relaxation would have positive effects as reported by some authors (Shih et al., 2017). In fact, after relaxing the muscles on the pectoral major, upper trapezius, upper trapezius, infraspinatus, infraspinatus, and posterior deltoid muscles (for about 30 minutes) combined with 15 minutes of a heating pad and 10 minutes of manual cyclo-ergometer, they were able to notice immediate effects on shoulder muscle performance, shoulder joint kinematics and pain. These results therefore indicate that pain and contractile tissue may have an influence on shoulder mobility and movement control abnormalities. This would therefore correlate quite well with studies that have been able to show the impact of muscle protection in physiopathology (Arjun & Rajaseker, 2021; Hollmann et al., 2018). â
In 2016, a systematic review carried out by Noten and his collaborators was able to show that Maitland-type mobilizations as well as spine mobilizations combined with shoulder stretching would be the most effective (Noten et al., 2016). â
Typical PNF techniques that emphasize diagonal movements and introduce resistance training seem more useful for restoring the joint structure of patients with frozen shoulder than traditional manual therapy. The PNF technique was also more effective than traditional manual therapy in relieving pain (Lin et al. 2022).
Thus, we understand that many possibilities are possible despite scientific evidence that is sometimes slight, such as a series of cases published in 2019 showing that manual therapy (including simple mobilizations, muscle relaxation techniques as well as techniques from Maitland or Mulligan) has interesting effects on amplitudes, pain and function (Dueñas et al., 2019).
In practice, the implementation of these techniques will depend mainly on the preferences of the therapist as well as on the irritability of the patient even if mobilizations with posterior sliding and those of the contract-relaxed type at the end of the amplitude seem to be the most effective (Srour & Nourissat, 2021).
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Among the most recommended techniques, we therefore find the posterior gliding of the glenohumeral joint. Patient in the dorsal recumbency, the therapist places one hand on the front part of the shoulder stump while the second hand fixes the proximal part of the glenohumeral joint with a âscapulo-clavicularâ clamp. The therapist then performs a traction coupled with a posterior sliding of the proximal part of the humerus. Note that as described in the literature, it will be possible to combine this technique with external rotations carried out with the help of a stick).
â Continuing the most fashionable techniques, we find contract-relaxed techniques that can be applied to muscles: pectoral muscle, major round, upper trapezius, posterior deltoid, infraspinatus or subscapular.
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A 2022 randomized controlled trial demonstrated the effectiveness and superiority of PNF techniques compared to traditional manual therapy. (Lin et al. 2022). The PNF technique introduces resistance training, where patients must coordinate their overall structure and movements to resist the given movement. This training can mobilize diseased tissue in such a way that it can be restored through gradual training (Costa et al. 2017). Therefore, these PNF techniques can be used as an effective complementary treatment for frozen shoulder.
Models of extension and flexure of the upper extremities. The upper extremities move at the diagonal angle (Lin et al. 2022)
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Extension and contraction of the shoulder girdle. Direction of the external force applied by the rehabilitation therapist (red arrow) and direction of the patient's shoulder against the external force (yellow arrow) (Lin et al.2022)
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Finally, after having addressed the techniques most recommended by the scientific literature (Maitland-type mobilization and relaxed contraction at the end of amplitude), other techniques that are less scientifically referenced could be used such as:
Subscapular relaxation techniques: patient in dorsal recumbency with the shoulder abducted and rotated externally (ideally 90° abduction and maximum external rotation). From this position, the therapist exerts sustained pressure on the trigger point of the subscapular. It would be possible to carry out pressure coupled with abduction movements and/or internal/external rotation (Dueñas et al., 2019). â
Mobilization of the glenohumeral artery in a caudal direction: used to limit abduction. The patient is sitting with his arms along his body. The therapist, lateral to the patient, makes one grip on the distal end of the humerus and the second is on the humeral head. It then carries out a pull in a caudal direction (Freddy M. Kaltenborn, 2006). â
Work on the sliding planes: the seated patient, the physiotherapist, laterally to the shoulder places the thumbs in the axillary hollow. The index fingers meet at the level of the acromioclavicular joint. The practitioner then performs lifting movements to relax the circumduction of the shoulder stump. Circumductions from front to back are then carried out. It is important to detect the possible protective contractions of the big three (big round, pectoral and latissimus dorsi) in order to inhibit them (Srour, 2008). â
Traction of the glenohumeral joint in the axis: patient in recumbency with the affected arm flexed at 90° and the elbow flexed at 90°. The patient places the mobilization belt close to the axillary hollow while one hand stabilizes the elbow and the other hand stabilizes the trunk. The therapist carries out a traction of the joint by means of a posterior weight transfer. This technique can be applied to all patients (Dueñas et al., 2019). â
Mobilizations of the âCodman paradoxâ type: patient in the supine position with the elbow bent at 90°, the therapist performs maximum flexure in the sagittal plane before performing a horizontal abduction in order to bring the shoulder into the position of abduction and external rotation (or in the position of âarmed with the armâ) without having achieved a pure external rotation that could have been sensitive (Cools, 2020).
A 2022 randomized controlled trial demonstrated the effectiveness of acromioclavicular mobilization on shoulder joint pain, disability, and mobility in patients with retractile capsulitis (Rahbar et al. 2022).
In this trial, the patient was placed in a supine position and the upper limb was placed in a physiological position with the patient's arm stuck to the body and the hand on the abdomen, which allowed the capsule to stretch less and the technique to be less painful. The therapist places the ends of his two thumbs on the front side of the collarbone adjacent to the acromioclavicular joint (AAC) and spreads his other fingers to ensure stability, and his forearm is located in the axis of the posterior movement at the level of the AAC (Rahbar et al. 2022).
Attention, this list is not exhaustive and it will always be necessary to enhance manual therapy according to the needs of the patient: scapular mobilizations, etc...
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Stretches
Having previously addressed manual therapy, it might have seemed logical to integrate these into manual therapy. However, in practice, many authors study stretching as a modality independent of manual therapy that can be carried out both passively by the therapist and actively by the patient in âself-stretchingâ. It therefore seemed necessary to approach it in isolation. So, we will discuss âcapsularâ stretching.
Regarding the scientific evidence on the subject, different stretching modalities (progressive static stretching (Ibrahim et al., 2014), inferior and/or posterior stretching of the capsule (Duzgun et al., 2019)) have been able to show good effects on patients with capsulitis. Similarly, combining stretching with mobilizations would have greater effects than carrying out mobilizations in isolation on amplitudes and functional scores after 1 year of follow-up (Ăelik & Kaya Mutlu, 2016).
Moreover, it is one of the only modalities to obtain a grade A during Nakalanda's last review of physiotherapy treatments for capsulitis (Nakandala et al., 2021). However, it should be remembered that the methodological quality of the studies carried out so far does not make it possible to identify one particular stretch compared to another.
In 2019, Duzgun and collaborators compared posterior capsular stretching with scapular mobilization and the two groups were crossed and re-evaluated after the first treatment. Significant improvements in range of motion were noted in both groups. However, no significant differences were found between groups (Duzgun et al., 2019).
In practice, the therapist will therefore have to implement stretching as well as âself-stretchingâ since the latter would be as effective as supervised stretching (Le et al., 2017). The intensity of these stretches will be determined by the patient's level of irritability (Srour & Nourissat, 2021). In order to facilitate the choice in the intensity of self-stretching, it is possible to approximate the progression algorithm described by Dueñas and his collaborators in their study (Dueñas et al., 2019):
Thus, the patient could be asked to perform self-stretching exercises such as:
Stretch with your hands clasped behind your head. â
Autonomous âCross arm stretchâ stretching: Patient standing, arms bent at 90°, he performs passive adduction using the opposite limb. However, the scapula has a tendency to sagittalize, reducing the tension on the posterior capsule (Delmares, 2016). â
Autonomous âroll over sleeper stretchâ stretch: the patient is in a lateral recumbency with the arm bent at 90°. In this position he performs a medial rotation using his second hand. The patient then rolls forward by 30 to 40° with an elevation of 50 to 60° only. However, it is little used due to the pain caused (Delmares, 2016). â
Stretching in âabduction and progressive external rotationâ: patient in the supine position with the shoulder abducted at 0-45-90° abduction and a weight of 1.5 kg in hand. It performs maximum lateral rotation until the necessary tension is obtained (Dueñas et al., 2019). This technique could correlate in particular to the clinical examination and to the need to focus the stretch on the subscapular, the anterior capsule or the inferior capsule ligament complex (Donatelli et al., 2014).
These stretches could be done several times a day, taking into account that the duration of application of the stretch, as well as the intensity, will evolve in an inversely proportional manner to irritability (the more irritability decreases, the more intense the stretch must be).
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Then, of course, it would be possible to propose passive stretching exercises performed by the therapist such as:
Manual stretching of the posterior capsule: patient in the dorsal recumbency, the therapist places his hands on either side of the humeral head with the thumbs facing each other on the front part of the humeral head. Performing a scapular countergrip using his other fingers, the therapist performs a posterior translation of the head with the aim of a posterior capsular stretch (Srour, 2008). â
Stretching of the rotator interval: patient in lateral recumbency on the painless side. The therapist's caudal hand fixes the patient's hand at the flank level in order to obtain an elbow bend of around 90°. From this position, using the caudal hand, he pushes the patient's elbow in the direction of the table in order to rotate the glenohumeral laterally (Dueñas et al., 2019).
It should be noted that the therapist will have an important educational role in teaching the patient to recognize the tension to be applied to the shoulder in order to avoid excessive tension in a phase of high irritability in particular. Indeed, a Diercks study was able to show that applying too intense stretching (and without respect for pain) could be counterproductive (Diercks & Stevens, 2004).
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Exercises
After talking about stretching and âself-stretchingâ, let's now focus on exercises. Although these have already been recommended for a few years (Kelley et al., 2013; Pandey & Madi, 2021), a recent review focused on this subject continues to show the positive effects of exercises on joint range, pain and functionality (Mertens et al., 2021). On the other hand, it sometimes seems more difficult to define which exercises to perform in order to optimize rehabilitation.
In fact, when we talk about exercises, we frequently refer to self-stretching without being interested in exercises such as strengthening the cuff muscles, strengthening the stabilizing muscles of the scapula or the kabat diagonals.
According to the latest studies published on the subject of exercises in the management of capsulitis, it appears that:
A program to strengthen the rotator cuff muscles would lead to a reduction in pain in the short term as well as an overall improvement in shoulder mobility and function (Rawat et al., 2017). â
The use of Kabat diagonals (or proprioceptive neuromuscular facilitation techniques) could lead to positive effects (on pain as well as on amplitudes) although not all authors agree on the subject (AkbaĆ et al., 2015; Balcı et al., 2016) â
Strengthening the lower trapezius in patients would be effective in reducing the anterior rocker in patients with capsulitis associated with an anterior rocker of the scapula (Abd Elhamed et al., 2018) â
Performing exercises in âeccentric contractionâ would provide better results than concentric contractions in women with capsulites (W.-M. Kim et al., 2021).
In practice, it would therefore be interesting to propose exercises to strengthen the rotator cuff as well as exercises using eccentric contractions. However, it will always be necessary to take into account the irritability threshold while fighting against the patient's possible kinesiophobia (Srour & Nourissat, 2021).
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Based on this data, it would be possible to propose different types of exercises such as:
Exercises targeted at strengthening the rotator cuff: isometric external rotation against a ball, external rotation with elastic resistance, etc... â
Exercises focused on the eccentric phase: flexure, extension, abduction, external rotation, pulling, etc... â
Lower trapezius recruitment exercises for patients with an anterior scapula tilt (Abd Elhamed et al., 2018):
--> Modified cobra: patient in prodecubitus on a mat/bench with arms at the side of the body and palms facing the sky. The patient extends the trunk in order to lift the trunk 10 cm off the ground. The thumb is then directed towards the sky and the hands point in the direction of the feet. The position is maintained for 10 seconds (Abd Elhamed et al., 2018; Arlotta et al., 2011)
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--> V-raise in prodecubitus: patient in prodecubitus with his arms abducted by 120° and his elbows extended, he raises his arms with his thumbs directed towards the sky. Each repetition is maintained 4-5 seconds at the end of the amplitude (Abd Elhamed et al., 2018).
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To these exercises, more classical âmobilityâ exercises could be added, such as:
Pendulum exercise. â
Exercise for amplitude gains in different positions and different planes (flexure, abduction, etc...)
On the other hand, âyogaâ does not seem to be effective in the treatment of capsulitis (M. Jain et al., 2020).
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â
Shockwaves
Not addressed in the 2013 APTA review (Kelley et al., 2013), this technique has attracted growing interest in the management of capsulitis to the point that it was considered by the latest Nakandala review as a grade A therapy for its effects on pain, amplitude and functionality. This technique therefore seems to have promising effects in the treatment of capsulitis in the same way as stretching or corticosteroid injections (Nakandala et al., 2021).
When we take a closer look at the latest studies on the subject, it turns out that:
A study carried out by Hussein and his collaborators was able to show that shock waves would lead to a significant reduction in pain perceived by the patient as well as an improvement in shoulder functionality and joint amplitudes in abduction and lateral rotation in the short and medium term (Hussein & Donatelli, 2016) (Hussein & Donatelli, 2016), although most of the subjects had presented with capsulitis for 11 months, resulting in an often lower stage of irritability. Then, other studies were able to confirm the effects (Chen et al., 2014). â
A study dating from 2017 was able to demonstrate that choice waves would be effective on diabetic patients with capsulitis to the point of offering them as an alternative to corticosteroid injections, which are not indicated for diabetic patients (Santoboni et al., 2017).
In the end, many authors agree that shock waves would be a good alternative for patients with diabetes or who cannot receive âcorticosteroidâ pain relievers (Pandey & Madi, 2021; Srour & Nourissat, 2021). This view was validated by a systematic review dating from 2022 indicating that shock waves could be beneficial in improving shoulder pain and function and that shock waves could be used as an adjunct to treatment despite a need to confirm the effects of this technique in the long term (R. Zhang et al., 2022).
In practice, shock waves could be produced by applying the probe to the back or front side of the shoulder by âaimingâ at possible adhesions. Regarding the frequency of use of this technique, most studies with positive effects used shock waves on a weekly basis (1 time per week) although other studies used it up to 3 times per week (R. Zhang et al., 2022)
â
Laser therapy :
Considered a grade A therapy in improving pain and joint amplitude (Nakandala et al., 2021), this therapy seems to be more effective than a placebo treatment in improving pain (T. K. Jain & Sharma, 2014; Page, Green, Sharma, 2014; Page, Green, Green, Kramer, Kramer, Johnston, McBain, & Buchbinder, 2014)
Cryotherapy (general and whole body)â:
When interested in cryotherapy, it is possible to implement local or whole-body cryotherapy:
Local cryotherapy: applied via pulsed cryotherapy or âcryopacksâ, it seems that it could be used to reduce the pain perceived at the end of the session (Srour, 2008). It could be used (in the same way as thermotherapy or electrotherapy) in combination with stretching to reduce perceived pain before, during, or after stretching (Srour & Nourissat, 2021) â
Whole-body cryotherapy: in 2013, Ma and his collaborators were able to prove that whole-body cryotherapy combined with physiotherapy modalities and passive joint mobilization was more effective in reducing pain, joint range and function than the group that only benefited from physiotherapy and passive joint mobilization modalities (Ma et al., 2013). In practice, whole-body cryotherapy consists in exposing the ânakedâ body in a chamber in which fresh air maintained between -110°C and -140°C circulates for a period of 2-3 minutes in order to obtain an anti-inflammatory and analgesic effect.
â
Other physiotherapy methods (TENS, ultrasound, etc.)
After having addressed cryotherapy, laser therapy or shock waves, it is now time to approach certain âphysiotherapeuticâ therapies.
Ultrasounds: their ineffectiveness has been proven by numerous studies, so they should not be recommended and/or used (T. K. Jain & Sharma, 2014). â
Electrotherapy such as âTENSâ: despite the lack of studies and reviews on the subject, some authors consider that they could be used in combination with stretching by using them before, after or during stretching to achieve short-term muscle relaxation (Rangan et al., 2016; Srour & Nourissat, 2021).
Dry Needling
A clinical case dating from 2014 was able to show the âeffectivenessâ of dry puncture in the treatment of capsulitis. The author states that he punctured the trapezius, infra and supraspinatus as well as the scapula elevator. He also reports that the patient was probably in a âfrozenâ phase, which made it possible to avoid significant irritability while working on muscular protective reactions. It therefore testifies to the effectiveness of this therapy in reducing pain and improving joint range of motion even if we should note that this cannot be considered significant. It would be interesting to test the effectiveness of the technique through the subscapular muscle (Clewley et al., 2014). These effects were able to be confirmed in a more recent study (Kalia et al., 2021) although future studies and reviews on the subject will need to be conducted in order to confirm the trend.
â
Motor imagery and mirror therapy
Mirror therapy used in combination with more classical rehabilitation would be effective in reducing pain, improving the amplitudes, functionality and quality of life of patients with capsulitis (BaĆkaya et al., 2018). In practice, it would be possible to make patients perform various movements (flexure, abduction, external rotation, etc.) starting first with the healthy side before performing the movements bilaterally while placing a mirror at the level of the patient's sagittal axis.
To go further on the subject, a case study dating from 2018 was able to show the effectiveness of a comprehensive graduated motor imaging program. Unlike mirror therapy, this program includes 4 steps: laterality training, tactile discrimination, imagined movements and mirror therapy. This program was delivered in combination with pain education on reducing irritability, fear of movement, and central awareness. Again, this is a clinical case with numerous limitations and other risks of bias (Sawyer et al., 2018) although a recent randomized trial reports positive effects on kinesiophobia, pain, and shoulder functionality (Gurudut & Godse, 2022).
In practice, this type of intervention seems relevant because of its so-called âtop-downâ approach to pain, where the objective will be mainly to act on possible central sensitization and high irritability. So, let's summarize the 4 steps of this program:
Laterality training: using a mobile application such asâ RecogniseÂźâ, the patient trains himself to recognize the ârightâ from the âleftâ on different parts of the body in different positions. â
Tactile discrimination: a photo of the painful shoulder is taken before writing 5 points on the photo. The patient is placed seated with a mirror along their sagittal axis (as with mirror therapy). The therapist then makes light touches on the painful shoulder while the patient must say which number is âtouchedâ. â
Imagined movements: during this stage, the therapist shows the patient 8 different shoulder postures (protraction, retraction, abduction, etc...). Then, he asks the patient to imagine his shoulder in the postures without moving. â
Mirror therapy: identical to the procedure described above.
â
4 - Integration of care
After discussing the various possible treatments for retractile capsulitis, it is essential to put them back into context with the concept of irritability.
It may be interesting to facilitate our approach by considering 2 main phases (Lewis, 2015):
A phase in which pain is more important than stiffness. â
A phase in which stiffness is more important than pain.
As a first step, When the pain is dominant, the main objective will be to reduce this pain. The therapist will be able to test different interventions recommended in the literature in order to see which ones best fit the patient.
In general, education will be very important during this phase, in particular to make the patient understand that any activity causing pain beyond 2/10 at the EVA must be temporarily prohibited in order to avoid maintaining the inflammatory process.
Indeed, the therapist will have to make sure that the shoulder does not remain inflamed for too long. The painful phase is a phase that should be tried to leave as soon as possible. Several techniques can be used during this phase to limit pain: stretching and gentle mobilizations, massages, techniques such as laser, TENS, cryotherapy, The infiltrations, acupuncture, exercises, etc...
In general, the therapist will remain in low levels of mobilization, outside the resistance zone. It is recommended to perform very gentle and very short stretching (from 1 to 5 seconds), pendulum exercises, gentle mobilization in external rotation (Chan et al., 2017; Dueñas et al., 2019), self-assisted and active movements (Lewis, 2015).
When we talk about âstretchingâ and mobilization, we are talking about movements in a sub-maximum and painless range (or at least up to 2/10 on the pain scale) (Lubis & Lubis, 2013). Indeed, solicitation beyond the pain threshold would seem to have lower results than infra-painful mobilizations. This would be due to the mechanosensitive properties of fibroblasts (Diercks & Stevens, 2004).
As we mentioned earlier, in parallel with rehabilitation, a corticosteroid injection could be useful in order to short circuit this phase where pain dominates over stiffness (Sun et al., 2017), especially during the first 6 weeks (Cho et al., 2019), especially during the first 6 weeks (Cho et al., 2019). Based on the results of a recent systematic review, the authors recommend the use of infiltrations for patients with a frozen shoulder lasting less than 1 year, as they seem to have earlier benefits than other interventions; the authors point out that these benefits could last up to 6 months (Challoumas et al., 2020).
It will also be important to offer the patient exercises to do at home between physiotherapy sessions. These exercises can be done 1 to 2 times per day. However, there is no evidence for the optimal frequency, number of repetitions, or duration of exercises (Kelley et al., 2013). The therapist should therefore warn the patient that all these exercises should be performed painlessly (possibly a maximum pain of 2/10 on the EVA can be tolerated).
â
Secondly, when the patient presents more stiffness than pain, the therapist can then accentuate his techniques, for example, by extending the static stretching postures (Donatelli et al., 2014). The therapist will be able to seek greater levels of mobilization, more powerful stretches by seeking resistance (Srour & Nourissat, 2021).
Gradually, the decaptations and slips in the humeral head may be greater while respecting the patient's tolerance and irritability, especially at the beginning of this new phase in order to prevent him from falling back into a more painful phase.
Patient education should be maintained throughout rehabilitation: it is important to talk to him about how he will feel, about the progression of the pathology etc. Later in this phase it may be interesting to offer the patient sessions with shock waves given the high level of evidence recently reported in the literature.
â
In a similar way, this therapeutic progression could have been achieved by following the âStaged Approach for Rehabilitation Classification: Shoulder Disordersâ (McClure & Michener, 2015). Consequently, instead of addressing the two phases described above, this time it would be a question of following the irritability of the tissue (although these are two related concepts). Thus, by following a review of recent literature (Mertens et al., 2022), it would be possible to define treatments according to the three phases of irritability:
â
Special case of the recently operated patient (manipulation under anesthesia, arthrolysis, etc...)
In patients undergoing surgery (arthrolysis, manipulation under anesthesia), post-operative rehabilitation should be started as soon as possible in order to maintain the amplitudes obtained during the operation (Cho et al., 2019). This information correlates in particular with a study indicating that 96% of British physiotherapists interviewed considered that physiotherapy follow-up was necessary post-operatively and that it should be started before 72 hours post-operatively (Willmore et al., 2021).
According to some authors, pain control with anti-inflammatories and/or cryotherapy is essential during the 2-3 post-operative weeks to abolish pain. Likewise, a structured physiotherapy follow-up must be put in place for 4 to 6 months in order to maintain the amplitudes. This follow-up should include passive and/or active joint mobilizations as well as exercises to strengthen the rotator cuff, scapular muscles and CORE muscles (Pandey & Madi, 2021). An independent stretching program to be performed at home 2-3 times a day should be offered to patients (Cho et al., 2019).
ââ
Examples of exercises
Phase 1: inflammatory phase/painful phase
â Phase 2: stiffness phase
â
âPhase 3: recovery phase
â
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Note: Find examples of treatments in videos based on the irritability of the patient at the bottom of this page
A - Prognosis
In general, one should not expect to have changes in the patient every 2 weeks, it is a pathology that takes time (Reeves et al. 1975). In fact, although retractile capsulitis generally occurs as a pathology resolutive (Hubbard et al. 2018; Xia et al. 2017), it can sometimes last up to 2 or 3 years or even never disappear completely (Zuckerman et al. 2011) with limited amplitudes as well as long-term pain (Le et al., 2017; 2017; Lewis, 2017; Lewis, 2017; Lewis, 2015; Manske & Prohaska, 2010; Wong et al., 2017). Factors with a âpoorâ prognosis include: diabetes, male sex or bilateral involvement. On the other hand, the duration of symptoms during the first visit does not seem to be linked to a poor prognosis (D. H. Kim et al., 2020). By focusing on diabetes, it is interesting to note that preliminary studies have been able to show that the prognosis may be poorer for people with diabetes (Dyer et al., 2021), which would correlate with previous studies that may have shown the frequent need to use other types of treatments (arthroscopies, etc.) following an inconclusive conservative treatment in diabetic patients (D. H. Kim et al. 2020; Rill et al., 2011). However, these cases would be the least frequent since conservative treatment would be effective in 90% of cases (Pandey & Madi, 2021)
b - General care recommendations
Although retractile capsulitis is a studied pathology, it is always curious to discover in the literature so many hypotheses and contradictions concerning the treatment of this pathology. Especially since it is a frequent, disabling pathology causing significant absenteeism at work.
In fact, empirical evidence suggests that some physiotherapy techniques and modalities are highly recommended for pain relief, improvement of range of motion, and functional status in patients with retractile capsule, while others are moderately or mildly recommended (Nakandala et al., 2021).
Thus, it is commonly accepted that the care Non-surgical, or conservative, should be the most appropriate treatment choice: most patients generally improve in 6 to 18 months (Georgiannos et al., 2017). In the absence of consensus on the best conservative therapeutic intervention, it is preferable to combine different treatment modalities (Page, Green, Kramer, Johnston, McBain, Chau, et al., 2014; Pandey & Madi, 2021) in order to adapt to the patient (Le et al., 2017).
Among the most recommended conservative treatments, we find physiotherapy through various active and passive treatments (Cho et al., 2019; Georgiannos et al., 2017; Kelley et al., 2013; Pandey & Madi, 2021; Rangan et al., 2015, 2016; Rangan et al., 2015, 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016; Vaishya et al., 2016 al., 2017; Pandey & Madi, 2021; Rangan et al., 2015, 2016; Vaishya et al., 2016; Yip et al., 2018) or the infiltrations (Cho et al., 2019; Georgiannos et al., 2019; Georgiannos et al., 2017; Georgiannos et al., 2017; Kelley et al., 2013; Pandey & Madi, 2021; Rangan et al., 2015, 2015; Vaishya et al., 2016; Yip et al., 2018).
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c - Medical treatments
With regard to medical treatment, numerous treatments have been proposed such as taking anti-inflammatories, injecting corticoids, manipulations under anesthesia, arthrolysis, etc...
1 - Oral medications
Taking anti-inflammatory drugs is frequently prescribed in the early stages of capsulitis in order to obtain a short-term reduction in pain (D'Orsi et al., 2012; Sumarwoto et al., 2021; Vaishya et al., 2016) by focusing on synovitis (Le et al., 2017). This intake could be considered for 2-3 weeks with the aim of allowing the patient to carry out their daily activities and physiotherapy more easily (Pandey & Madi, 2021) although these drugs do not have an impact on the natural evolution of capsulitis (Cho et al., 2019).
Taking corticosteroids could have effects on pain (and in particular nocturnal pain) as well as on short-term joint range (Sumarwoto et al., 2021; Yip et al., 2018) in the âfreezingâ or âfrozenâ phases where inflammation persists (Pandey & Madi, 2021). Oral steroids could have positive effects on pain and range of motion in the short term despite the risk of side effects (Pandey & Madi, 2021).
Of course, these treatments must be carried out in conjunction with a physiotherapeutic treatment of the âmanual therapyâ type (Page, Green, Kramer, Johnston, McBain, Chau, et al., 2014). â
A randomized controlled trial comparing oral corticosteroids and exercises in the treatment of retractile capsulitis. Both groups improved with superior results in terms of external rotation and abduction in the exercise group and side effects in the anti-inflammatory group, even at low doses.
2 - Bee venom acupuncture
Described as a grade A therapy in the rehabilitation of capsulitis (Nakandala et al., 2021), acupuncture with bee venom could present interesting effects. Indeed, according to Koh and his collaborators, bee venom acupuncture (AVA) combined with physiotherapy treatment over a follow-up period of 12 weeks would have superior effects compared to a group that simply followed a physiotherapy treatment (composed of TENS, thermotherapy and manual therapy) (Koh et al., 2013). The reported effectiveness in reducing pain and improving function was re-evaluated retrospectively 1 year later by Park and her team. The authors found that the effects remained clinically effective 1 year after treatment and may contribute to improved long-term quality of life for patients with retractile capsulitis (Park et al., 2014).
While this technique could be interesting, there is however little scientific evidence concerning the use of this technique in daily practice for primary capsules (Rangan et al., 2016). In addition, although it is often described in âphysiotherapyâ treatments, it is still essential to remember that injecting products through the skin barrier is not part of the physiotherapist's field of expertise. Thus, unlike dry puncture (or âDry Needlingâ), this acupuncture with bee venom would therefore not be the responsibility of physiotherapists.
3 - Infiltrations
Intra-articular injection of corticosteroids by means of an infiltration would allow a rapid improvement in pain and joint amplitudes in the short (Srour & Nourissat, 2021) and medium term (Pandey & Madi, 2021) by suppressing the inflammatory response, and therefore, by extension, by limiting the differentiation of fibroblasts into myofibroblasts (Hettrich et al., 2021) by suppressing the inflammatory response, and therefore, by extension, by limiting the differentiation of fibroblasts into myofibroblasts (Hettrich et al., 2016).
In terms of effectiveness, combining infiltrations with mobility and stretching exercises would be more effective in the short term than exercises performed in isolation (Kelley et al., 2013). In addition, some authors show that injections would be more effective than oral corticosteroids (Le et al., 2017; Lorbach et al., 2010), while others consider that these injections would slow or even stop the progression of this pathology (Hettrich et al., 2016). In the long term, there would be no differences in effectiveness with physiotherapy treatment, oral corticosteroids and/or anti-inflammatories (Yip et al., 2018) even though some authors consider that infiltration would probably be one of the best current treatments for capsulitis (Challoumas et al., 2020).
Concretely, the technique consists in injecting Triamcinolone or Methylprednisolone into the shoulder (intra-articularly or in the rotator interval or in the sub-acromial space) noting that none of the injection sites seems superior to another. On the other hand, it seems that triamcinolone has effects that are sometimes greater than those of methylprednisolone and that the infiltration should be carried out all at once (Pandey & Madi, 2021). These infiltrations could be associated with manipulations as shown by some authors (Y. Zhang et al., 2022). In addition, a low dose of corticosteroids with a self-rehabilitation program would be more effective than a large dose of corticosteroids without a self-rehabilitation program (Minns Lowe et al., 2019). It is also interesting to note that at most the corticosteroid injection is Administered early in the process of pathology, the greater the effect on clinical symptoms. Corticosteroids may suppress the inflammatory response, but they cannot reverse fibrotic changes later in the cascade. When administered later in the stiffness stage, the effect of corticosteroids is generally more temporary (Ahn et al., 2018).
Note that this technique should be avoided for people with uncontrolled diabetes. Likewise, some minor side effects may occur such as: flushing, chest or shoulder pain, dizziness or nausea (Pandey & Madi, 2021).
Finally, while we have mainly addressed corticosteroid infiltrations, it seems important to emphasize that new systematic reviews show the effectiveness of hyaluronic acid infiltration into capsulitis in improving pain and joint amplitudes (Mao et al., 2022).
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4 - Arthrodilation (or Hydrodilation)
Technique used since the 1960s to treat capsulitis (Cho et al., 2019), it is often associated with infiltrations, the effectiveness of this technique has long been questioned (D'Orsi et al., 2012; Yip et al., 2018) although recent studies seem to show the effectiveness of hydrodilation combined with infiltration compared to an infiltration carried out alone (Challoumas et al., 2020; Yip et al., 2018) although recent studies seem to show the effectiveness of hydrodilation combined with infiltration in comparison to an infiltration carried out alone (Challoumas et al., 2020; Yip et al., 2018) although recent studies seem to show the effectiveness of hydrodilation combined with infiltration in comparison to an infiltration carried out alone (Challoumas et al., 2020; Yip et al., 2018) although recent studies seem to show the effectiveness of hydrodilation combined 2021).
In practice, the technique consists in injecting air or liquid into the capsule in order to stretch the capsule and allow an increase in the capsule volume. This technique is performed under fluoroscopy (Le et al., 2017). On the other hand, it could not be established whether capsule rupture should be achieved or if only capsule distension is necessary (Cho et al., 2019)
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5 - Manipulation under anesthesia
This technique consists in manipulating the capsule ligament complex on the patient's shoulder when the patient is under general anesthesia or inter-scalenic block. Concretely, once under anesthesia, the patient's shoulder is brought into flexure, abduction followed by external and/or internal rotations with arms at 90° abduction in order to stretch the retracted tissue (Pandey & Madi, 2021).
This manipulation is generally proposed in case of failure of conservative treatment lasting at least 6 months (Srour & Nourissat, 2021). In addition, offering this technique between 6 and 9 months after the onset of symptoms could be the most appropriate since an early implementation of this technique in the more âacuteâ phase could lead to a worsening of the symptoms (VastamĂ€ki et al., 2015). Regarding the technique, it should not necessarily be accompanied by infiltration although some practitioners appreciate this complementarity. In addition, it would present more moderate results in diabetic patients (Pandey & Madi, 2021).
This technique would have positive effects on improving pain, mobility function as well as on patient satisfaction (Kraal et al., 2019).
However, it should be noted that manipulation under anesthesia must be followed by physiotherapy in order to ensure the maintenance of the gains obtained (Srour & Nourissat, 2021).
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6 - Arthrolysis
The last âmedicalâ technique discussed, arthrolysis under arthroscopy seems effective in improving pain and mobility in patients in the short, medium and long term (Gleyze et al., 2011) while allowing the surgeon to obtain a direct view of the joint and to correct associated lesions (labrum, etc...) (Pandey & Madi, 2021). In the same way as for manipulation under anesthesia, the latter should only be considered in case of failure of conservative treatment after 6 months.
Regarding the duality between manipulation under anesthesia and arthrolysis, it seems that arthrolysis would present less risk of complications than mobilization under anesthesia with good results in diabetic patients (Ăınar et al., 2010; Grant et al., 2013). Note that no study can prove the superiority of one technique over the other (Pandey & Madi, 2021; Yip et al., 2018). On the other hand, the decision to perform arthrolysis would most often depend on the patient. Indeed, while the majority of capsulites resolve with conservative treatment within 1-2 years, some patients with a high level of activity prefer arthrolysis in order to accelerate recovery (Gordon et al., 2016).
In some cases, arthrolysis may be performed through open surgery when arthrolysis under arthroscopy is not able to improve joint pain or range of motion. In this case, a release of the coracohumeral ligament and the rotator interval is performed in order to obtain an improvement in joint range and pain (Le et al., 2017).
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d - Physiotherapy treatment
After having discussed the medical treatment that can be offered in retractile capsule, it is now time to focus on physiotherapeutic treatments. However, before detailing the various applicable modalities, it seems appropriate to first focus on the main recommendations and then to review the âirritabilityâ model as described by McClure in 2015 (McClure & Michener, 2015).
When we refer to the guidelines published by the APTA in 2013, it seems that rehabilitation should include therapeutic education, mobilizations and manipulations, stretching as well as other tools such as diathermy or electrotherapy (Kelley et al., 2013).
Despite all these studies, it still seems difficult to sort out the best treatments since most of the studies carried out so far are of low methodological quality or have different methods. It is therefore not easy to compare treatments with each other (Minns Lowe et al., 2019; Yip et al., 2018).
In this regard, some authors have suggested that among physiotherapy modalities, shock waves, stretching and laser therapy may represent the most recommended therapies in 2021 (Nakandala et al., 2021).
Consequently, it is therefore important to rely on another point of interest in rehabilitation: the concept of irritability.
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2 - Irritability and rehabilitation
As mentioned earlier, irritability is a key point in choosing the techniques to be addressed. Widely acclaimed by many authors (Cools, 2020; Lewis, 2015), it will aim to adapt treatment according to tissue irritability. Thus, if the patient has a profile that can be assimilated to the category âhigh irritabilityâ, âmedium irritabilityâ or âlow irritabilityâ, the treatment objectives will be adapted to the latter:
In high irritability: minimize physical stress, modify activities, and monitor for deficiencies. â
In moderate irritability: propose moderate physical stress, treat deficiencies and restore basic functional activities. â
In low irritability: propose high physical stresses, treat deficiencies and restore complex functional activities.
In order to facilitate clinical reasoning, it may be interesting at the beginning of the session to ask yourself the right questions as proposed in the study by Kareha and her collaborators (Kareha et al., 2021):
Thus, depending on the answers to these questions, it may be possible to quickly establish session goals with the appropriate tools.
By following this logic of irritability, it is once again possible to approach the recommendations for the management of retractile capsule proposed by the APTA in 2013 (Kelley et al., 2013, p. 20). This document was then based on literature from the 20th century up to 2011 in order to establish which techniques were of real interest in order to meet the rehabilitation objectives set in the context of the management of retractile capsule of the shoulder.
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3 - Therapeutic means
After having discussed the techniques proposed in 2013 by APTA and having previously shown that many methods have been able to demonstrate their effectiveness, it is now time to discuss the different treatment modalities. Of course, it will be necessary to integrate the concept of irritability in order to understand the treatment as a whole.
We will therefore first discuss the most widely recommended treatments such as therapeutic education, manual therapy, exercises or stretching before looking at other possible treatments such as thermotherapy, cryotherapy, acupuncture, acupuncture, acupuncture, acupuncture, electrotherapy, electrotherapy, electrotherapy, electrotherapy, electrotherapy, shock waves, ultrasound, diathermy, etc.
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Therapeutic education
Since 2013, all experts agree in recommending that clinicians conduct therapeutic education (Kelley et al., 2013). An essential point of treatment, it should therefore be implemented early and should allow (Kelley et al., 2013; Rangan et al., 2016):
To understand what a capsule is (an âinflammation of the capsule evolving into fibrosisâ), its benign nature and its evolution (not to mention that it is better to avoid talking about a âself-limitingâ pathology). â
To explain the different therapeutic options and their effectiveness in order to co-construct the ideal treatment. â
To explain the importance of the patient's adherence to treatment by insisting on the importance of carrying out the exercises independently (self-stretching, etc.)
This education will therefore make it possible to promote patient adherence and participation by avoiding âpassiveâ patients waiting for spontaneous resolution.
Also, it will be important to promote the modification of activities in order to carry out painless activities in a maximum range of activities. Likewise, it is essential for the patient to understand that he must adapt the intensity of the stretching (or treatment) to his stage of irritability (Kelley et al., 2013).
To go further in patient education, it should be noted that some studies suggest integrating pain education by explaining to the patient that pain comes from the brain, that it is not always associated with tissue damage, that the environment can influence the intensity of perceived pain, and that persistent pain can increase sensitivity to it (Sawyer et al., 2018).
Likewise, the identification of psychosocial factors revealed by questionnaires such as the âCastrophism Scal Breadâ Or the âTampa Scale of Kinesiophobiaâ for example, may encourage the therapist to employ specific patient education strategies in order to optimize the beneficial effects of interventions.
In 2015, Jeremy Lewis spoke of an essential first step in patient education. The therapist should be able to answer the patient's various questions, namely:
What do I have? â
What is the cause of the problem? â
How long is this going to last? â
What is the prognosis? â
What treatments are offered? â
What are the expected results?
Note that 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.
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Manual therapy
Manual therapy, in the context of retractile capsulitis, could be similar to âmanual techniquesâ applied to the patient's shoulder. The latter include simple passive mobilizations, manipulations, but also mobilizations resulting from different currents of thought such as techniques from Mulligan, Kaltenborn or Maitland for example.
When we look at the scientific evidence for manual therapy, it seems that:
Simple joint mobilizations combined with stretching allow an improvement in the amplitude of external rotation and abduction while improving functional scores at 1 year compared to stretching alone (Ăelik & Kaya Mutlu, 2016). On the other hand, these results were not found by Khan and his collaborators when they compared the mobilizations with exercises to exercises carried out in isolation (Khan, 2015). â
Mulligan techniques are effective in reducing pain and restoring range of motion and shoulder function when compared to a treatment consisting of heat therapy, electrotherapy, and passive stretching exercises (Doner et al., 2013). â
Techniques such as muscle relaxation would have positive effects as reported by some authors (Shih et al., 2017). In fact, after relaxing the muscles on the pectoral major, upper trapezius, upper trapezius, infraspinatus, infraspinatus, and posterior deltoid muscles (for about 30 minutes) combined with 15 minutes of a heating pad and 10 minutes of manual cyclo-ergometer, they were able to notice immediate effects on shoulder muscle performance, shoulder joint kinematics and pain. These results therefore indicate that pain and contractile tissue may have an influence on shoulder mobility and movement control abnormalities. This would therefore correlate quite well with studies that have been able to show the impact of muscle protection in physiopathology (Arjun & Rajaseker, 2021; Hollmann et al., 2018). â
In 2016, a systematic review carried out by Noten and his collaborators was able to show that Maitland-type mobilizations as well as spine mobilizations combined with shoulder stretching would be the most effective (Noten et al., 2016). â
Typical PNF techniques that emphasize diagonal movements and introduce resistance training seem more useful for restoring the joint structure of patients with frozen shoulder than traditional manual therapy. The PNF technique was also more effective than traditional manual therapy in relieving pain (Lin et al. 2022).
Thus, we understand that many possibilities are possible despite scientific evidence that is sometimes slight, such as a series of cases published in 2019 showing that manual therapy (including simple mobilizations, muscle relaxation techniques as well as techniques from Maitland or Mulligan) has interesting effects on amplitudes, pain and function (Dueñas et al., 2019).
In practice, the implementation of these techniques will depend mainly on the preferences of the therapist as well as on the irritability of the patient even if mobilizations with posterior sliding and those of the contract-relaxed type at the end of the amplitude seem to be the most effective (Srour & Nourissat, 2021).
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Among the most recommended techniques, we therefore find the posterior gliding of the glenohumeral joint. Patient in the dorsal recumbency, the therapist places one hand on the front part of the shoulder stump while the second hand fixes the proximal part of the glenohumeral joint with a âscapulo-clavicularâ clamp. The therapist then performs a traction coupled with a posterior sliding of the proximal part of the humerus. Note that as described in the literature, it will be possible to combine this technique with external rotations carried out with the help of a stick).
â Continuing the most fashionable techniques, we find contract-relaxed techniques that can be applied to muscles: pectoral muscle, major round, upper trapezius, posterior deltoid, infraspinatus or subscapular.
â
A 2022 randomized controlled trial demonstrated the effectiveness and superiority of PNF techniques compared to traditional manual therapy. (Lin et al. 2022). The PNF technique introduces resistance training, where patients must coordinate their overall structure and movements to resist the given movement. This training can mobilize diseased tissue in such a way that it can be restored through gradual training (Costa et al. 2017). Therefore, these PNF techniques can be used as an effective complementary treatment for frozen shoulder.
Models of extension and flexure of the upper extremities. The upper extremities move at the diagonal angle (Lin et al. 2022)
Extension and contraction of the shoulder girdle. Direction of the external force applied by the rehabilitation therapist (red arrow) and direction of the patient's shoulder against the external force (yellow arrow) (Lin et al.2022)
Finally, after having addressed the techniques most recommended by the scientific literature (Maitland-type mobilization and relaxed contraction at the end of amplitude), other techniques that are less scientifically referenced could be used such as:
Subscapular relaxation techniques: patient in dorsal recumbency with the shoulder abducted and rotated externally (ideally 90° abduction and maximum external rotation). From this position, the therapist exerts sustained pressure on the trigger point of the subscapular. It would be possible to carry out pressure coupled with abduction movements and/or internal/external rotation (Dueñas et al., 2019). â
Mobilization of the glenohumeral artery in a caudal direction: used to limit abduction. The patient is sitting with his arms along his body. The therapist, lateral to the patient, makes one grip on the distal end of the humerus and the second is on the humeral head. It then carries out a pull in a caudal direction (Freddy M. Kaltenborn, 2006). â
Work on the sliding planes: the seated patient, the physiotherapist, laterally to the shoulder places the thumbs in the axillary hollow. The index fingers meet at the level of the acromioclavicular joint. The practitioner then performs lifting movements to relax the circumduction of the shoulder stump. Circumductions from front to back are then carried out. It is important to detect the possible protective contractions of the big three (big round, pectoral and latissimus dorsi) in order to inhibit them (Srour, 2008). â
Traction of the glenohumeral joint in the axis: patient in recumbency with the affected arm flexed at 90° and the elbow flexed at 90°. The patient places the mobilization belt close to the axillary hollow while one hand stabilizes the elbow and the other hand stabilizes the trunk. The therapist carries out a traction of the joint by means of a posterior weight transfer. This technique can be applied to all patients (Dueñas et al., 2019). â
Mobilizations of the âCodman paradoxâ type: patient in the supine position with the elbow bent at 90°, the therapist performs maximum flexure in the sagittal plane before performing a horizontal abduction in order to bring the shoulder into the position of abduction and external rotation (or in the position of âarmed with the armâ) without having achieved a pure external rotation that could have been sensitive (Cools, 2020).
A 2022 randomized controlled trial demonstrated the effectiveness of acromioclavicular mobilization on shoulder joint pain, disability, and mobility in patients with retractile capsulitis (Rahbar et al. 2022).
In this trial, the patient was placed in a supine position and the upper limb was placed in a physiological position with the patient's arm stuck to the body and the hand on the abdomen, which allowed the capsule to stretch less and the technique to be less painful. The therapist places the ends of his two thumbs on the front side of the collarbone adjacent to the acromioclavicular joint (AAC) and spreads his other fingers to ensure stability, and his forearm is located in the axis of the posterior movement at the level of the AAC (Rahbar et al. 2022).
Attention, this list is not exhaustive and it will always be necessary to enhance manual therapy according to the needs of the patient: scapular mobilizations, etc...
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Stretches
Having previously addressed manual therapy, it might have seemed logical to integrate these into manual therapy. However, in practice, many authors study stretching as a modality independent of manual therapy that can be carried out both passively by the therapist and actively by the patient in âself-stretchingâ. It therefore seemed necessary to approach it in isolation. So, we will discuss âcapsularâ stretching.
Regarding the scientific evidence on the subject, different stretching modalities (progressive static stretching (Ibrahim et al., 2014), inferior and/or posterior stretching of the capsule (Duzgun et al., 2019)) have been able to show good effects on patients with capsulitis. Similarly, combining stretching with mobilizations would have greater effects than carrying out mobilizations in isolation on amplitudes and functional scores after 1 year of follow-up (Ăelik & Kaya Mutlu, 2016).
Moreover, it is one of the only modalities to obtain a grade A during Nakalanda's last review of physiotherapy treatments for capsulitis (Nakandala et al., 2021). However, it should be remembered that the methodological quality of the studies carried out so far does not make it possible to identify one particular stretch compared to another.
In 2019, Duzgun and collaborators compared posterior capsular stretching with scapular mobilization and the two groups were crossed and re-evaluated after the first treatment. Significant improvements in range of motion were noted in both groups. However, no significant differences were found between groups (Duzgun et al., 2019).
In practice, the therapist will therefore have to implement stretching as well as âself-stretchingâ since the latter would be as effective as supervised stretching (Le et al., 2017). The intensity of these stretches will be determined by the patient's level of irritability (Srour & Nourissat, 2021). In order to facilitate the choice in the intensity of self-stretching, it is possible to approximate the progression algorithm described by Dueñas and his collaborators in their study (Dueñas et al., 2019):
Thus, the patient could be asked to perform self-stretching exercises such as:
Stretch with your hands clasped behind your head. â
Autonomous âCross arm stretchâ stretching: Patient standing, arms bent at 90°, he performs passive adduction using the opposite limb. However, the scapula has a tendency to sagittalize, reducing the tension on the posterior capsule (Delmares, 2016). â
Autonomous âroll over sleeper stretchâ stretch: the patient is in a lateral recumbency with the arm bent at 90°. In this position he performs a medial rotation using his second hand. The patient then rolls forward by 30 to 40° with an elevation of 50 to 60° only. However, it is little used due to the pain caused (Delmares, 2016). â
Stretching in âabduction and progressive external rotationâ: patient in the supine position with the shoulder abducted at 0-45-90° abduction and a weight of 1.5 kg in hand. It performs maximum lateral rotation until the necessary tension is obtained (Dueñas et al., 2019). This technique could correlate in particular to the clinical examination and to the need to focus the stretch on the subscapular, the anterior capsule or the inferior capsule ligament complex (Donatelli et al., 2014).
These stretches could be done several times a day, taking into account that the duration of application of the stretch, as well as the intensity, will evolve in an inversely proportional manner to irritability (the more irritability decreases, the more intense the stretch must be).
â
Then, of course, it would be possible to propose passive stretching exercises performed by the therapist such as:
Manual stretching of the posterior capsule: patient in the dorsal recumbency, the therapist places his hands on either side of the humeral head with the thumbs facing each other on the front part of the humeral head. Performing a scapular countergrip using his other fingers, the therapist performs a posterior translation of the head with the aim of a posterior capsular stretch (Srour, 2008). â
Stretching of the rotator interval: patient in lateral recumbency on the painless side. The therapist's caudal hand fixes the patient's hand at the flank level in order to obtain an elbow bend of around 90°. From this position, using the caudal hand, he pushes the patient's elbow in the direction of the table in order to rotate the glenohumeral laterally (Dueñas et al., 2019).
It should be noted that the therapist will have an important educational role in teaching the patient to recognize the tension to be applied to the shoulder in order to avoid excessive tension in a phase of high irritability in particular. Indeed, a Diercks study was able to show that applying too intense stretching (and without respect for pain) could be counterproductive (Diercks & Stevens, 2004).
â
Exercises
After talking about stretching and âself-stretchingâ, let's now focus on exercises. Although these have already been recommended for a few years (Kelley et al., 2013; Pandey & Madi, 2021), a recent review focused on this subject continues to show the positive effects of exercises on joint range, pain and functionality (Mertens et al., 2021). On the other hand, it sometimes seems more difficult to define which exercises to perform in order to optimize rehabilitation.
In fact, when we talk about exercises, we frequently refer to self-stretching without being interested in exercises such as strengthening the cuff muscles, strengthening the stabilizing muscles of the scapula or the kabat diagonals.
According to the latest studies published on the subject of exercises in the management of capsulitis, it appears that:
A program to strengthen the rotator cuff muscles would lead to a reduction in pain in the short term as well as an overall improvement in shoulder mobility and function (Rawat et al., 2017). â
The use of Kabat diagonals (or proprioceptive neuromuscular facilitation techniques) could lead to positive effects (on pain as well as on amplitudes) although not all authors agree on the subject (AkbaĆ et al., 2015; Balcı et al., 2016) â
Strengthening the lower trapezius in patients would be effective in reducing the anterior rocker in patients with capsulitis associated with an anterior rocker of the scapula (Abd Elhamed et al., 2018) â
Performing exercises in âeccentric contractionâ would provide better results than concentric contractions in women with capsulites (W.-M. Kim et al., 2021).
In practice, it would therefore be interesting to propose exercises to strengthen the rotator cuff as well as exercises using eccentric contractions. However, it will always be necessary to take into account the irritability threshold while fighting against the patient's possible kinesiophobia (Srour & Nourissat, 2021).
â
Based on this data, it would be possible to propose different types of exercises such as:
Exercises targeted at strengthening the rotator cuff: isometric external rotation against a ball, external rotation with elastic resistance, etc... â
Exercises focused on the eccentric phase: flexure, extension, abduction, external rotation, pulling, etc... â
Lower trapezius recruitment exercises for patients with an anterior scapula tilt (Abd Elhamed et al., 2018):
--> Modified cobra: patient in prodecubitus on a mat/bench with arms at the side of the body and palms facing the sky. The patient extends the trunk in order to lift the trunk 10 cm off the ground. The thumb is then directed towards the sky and the hands point in the direction of the feet. The position is maintained for 10 seconds (Abd Elhamed et al., 2018; Arlotta et al., 2011)
â
--> V-raise in prodecubitus: patient in prodecubitus with his arms abducted by 120° and his elbows extended, he raises his arms with his thumbs directed towards the sky. Each repetition is maintained 4-5 seconds at the end of the amplitude (Abd Elhamed et al., 2018).
â
â
To these exercises, more classical âmobilityâ exercises could be added, such as:
Pendulum exercise. â
Exercise for amplitude gains in different positions and different planes (flexure, abduction, etc...)
On the other hand, âyogaâ does not seem to be effective in the treatment of capsulitis (M. Jain et al., 2020).
â
â
Shockwaves
Not addressed in the 2013 APTA review (Kelley et al., 2013), this technique has attracted growing interest in the management of capsulitis to the point that it was considered by the latest Nakandala review as a grade A therapy for its effects on pain, amplitude and functionality. This technique therefore seems to have promising effects in the treatment of capsulitis in the same way as stretching or corticosteroid injections (Nakandala et al., 2021).
When we take a closer look at the latest studies on the subject, it turns out that:
A study carried out by Hussein and his collaborators was able to show that shock waves would lead to a significant reduction in pain perceived by the patient as well as an improvement in shoulder functionality and joint amplitudes in abduction and lateral rotation in the short and medium term (Hussein & Donatelli, 2016) (Hussein & Donatelli, 2016), although most of the subjects had presented with capsulitis for 11 months, resulting in an often lower stage of irritability. Then, other studies were able to confirm the effects (Chen et al., 2014). â
A study dating from 2017 was able to demonstrate that choice waves would be effective on diabetic patients with capsulitis to the point of offering them as an alternative to corticosteroid injections, which are not indicated for diabetic patients (Santoboni et al., 2017).
In the end, many authors agree that shock waves would be a good alternative for patients with diabetes or who cannot receive âcorticosteroidâ pain relievers (Pandey & Madi, 2021; Srour & Nourissat, 2021). This view was validated by a systematic review dating from 2022 indicating that shock waves could be beneficial in improving shoulder pain and function and that shock waves could be used as an adjunct to treatment despite a need to confirm the effects of this technique in the long term (R. Zhang et al., 2022).
In practice, shock waves could be produced by applying the probe to the back or front side of the shoulder by âaimingâ at possible adhesions. Regarding the frequency of use of this technique, most studies with positive effects used shock waves on a weekly basis (1 time per week) although other studies used it up to 3 times per week (R. Zhang et al., 2022)
â
Laser therapy :
Considered a grade A therapy in improving pain and joint amplitude (Nakandala et al., 2021), this therapy seems to be more effective than a placebo treatment in improving pain (T. K. Jain & Sharma, 2014; Page, Green, Sharma, 2014; Page, Green, Green, Kramer, Kramer, Johnston, McBain, & Buchbinder, 2014)
Cryotherapy (general and whole body)â:
When interested in cryotherapy, it is possible to implement local or whole-body cryotherapy:
Local cryotherapy: applied via pulsed cryotherapy or âcryopacksâ, it seems that it could be used to reduce the pain perceived at the end of the session (Srour, 2008). It could be used (in the same way as thermotherapy or electrotherapy) in combination with stretching to reduce perceived pain before, during, or after stretching (Srour & Nourissat, 2021) â
Whole-body cryotherapy: in 2013, Ma and his collaborators were able to prove that whole-body cryotherapy combined with physiotherapy modalities and passive joint mobilization was more effective in reducing pain, joint range and function than the group that only benefited from physiotherapy and passive joint mobilization modalities (Ma et al., 2013). In practice, whole-body cryotherapy consists in exposing the ânakedâ body in a chamber in which fresh air maintained between -110°C and -140°C circulates for a period of 2-3 minutes in order to obtain an anti-inflammatory and analgesic effect.
â
Other physiotherapy methods (TENS, ultrasound, etc.)
After having addressed cryotherapy, laser therapy or shock waves, it is now time to approach certain âphysiotherapeuticâ therapies.
Ultrasounds: their ineffectiveness has been proven by numerous studies, so they should not be recommended and/or used (T. K. Jain & Sharma, 2014). â
Electrotherapy such as âTENSâ: despite the lack of studies and reviews on the subject, some authors consider that they could be used in combination with stretching by using them before, after or during stretching to achieve short-term muscle relaxation (Rangan et al., 2016; Srour & Nourissat, 2021).
Dry Needling
A clinical case dating from 2014 was able to show the âeffectivenessâ of dry puncture in the treatment of capsulitis. The author states that he punctured the trapezius, infra and supraspinatus as well as the scapula elevator. He also reports that the patient was probably in a âfrozenâ phase, which made it possible to avoid significant irritability while working on muscular protective reactions. It therefore testifies to the effectiveness of this therapy in reducing pain and improving joint range of motion even if we should note that this cannot be considered significant. It would be interesting to test the effectiveness of the technique through the subscapular muscle (Clewley et al., 2014). These effects were able to be confirmed in a more recent study (Kalia et al., 2021) although future studies and reviews on the subject will need to be conducted in order to confirm the trend.
â
Motor imagery and mirror therapy
Mirror therapy used in combination with more classical rehabilitation would be effective in reducing pain, improving the amplitudes, functionality and quality of life of patients with capsulitis (BaĆkaya et al., 2018). In practice, it would be possible to make patients perform various movements (flexure, abduction, external rotation, etc.) starting first with the healthy side before performing the movements bilaterally while placing a mirror at the level of the patient's sagittal axis.
To go further on the subject, a case study dating from 2018 was able to show the effectiveness of a comprehensive graduated motor imaging program. Unlike mirror therapy, this program includes 4 steps: laterality training, tactile discrimination, imagined movements and mirror therapy. This program was delivered in combination with pain education on reducing irritability, fear of movement, and central awareness. Again, this is a clinical case with numerous limitations and other risks of bias (Sawyer et al., 2018) although a recent randomized trial reports positive effects on kinesiophobia, pain, and shoulder functionality (Gurudut & Godse, 2022).
In practice, this type of intervention seems relevant because of its so-called âtop-downâ approach to pain, where the objective will be mainly to act on possible central sensitization and high irritability. So, let's summarize the 4 steps of this program:
Laterality training: using a mobile application such asâ RecogniseÂźâ, the patient trains himself to recognize the ârightâ from the âleftâ on different parts of the body in different positions. â
Tactile discrimination: a photo of the painful shoulder is taken before writing 5 points on the photo. The patient is placed seated with a mirror along their sagittal axis (as with mirror therapy). The therapist then makes light touches on the painful shoulder while the patient must say which number is âtouchedâ. â
Imagined movements: during this stage, the therapist shows the patient 8 different shoulder postures (protraction, retraction, abduction, etc...). Then, he asks the patient to imagine his shoulder in the postures without moving. â
Mirror therapy: identical to the procedure described above.
â
4 - Integration of care
After discussing the various possible treatments for retractile capsulitis, it is essential to put them back into context with the concept of irritability.
It may be interesting to facilitate our approach by considering 2 main phases (Lewis, 2015):
A phase in which pain is more important than stiffness. â
A phase in which stiffness is more important than pain.
As a first step, When the pain is dominant, the main objective will be to reduce this pain. The therapist will be able to test different interventions recommended in the literature in order to see which ones best fit the patient.
In general, education will be very important during this phase, in particular to make the patient understand that any activity causing pain beyond 2/10 at the EVA must be temporarily prohibited in order to avoid maintaining the inflammatory process.
Indeed, the therapist will have to make sure that the shoulder does not remain inflamed for too long. The painful phase is a phase that should be tried to leave as soon as possible. Several techniques can be used during this phase to limit pain: stretching and gentle mobilizations, massages, techniques such as laser, TENS, cryotherapy, The infiltrations, acupuncture, exercises, etc...
In general, the therapist will remain in low levels of mobilization, outside the resistance zone. It is recommended to perform very gentle and very short stretching (from 1 to 5 seconds), pendulum exercises, gentle mobilization in external rotation (Chan et al., 2017; Dueñas et al., 2019), self-assisted and active movements (Lewis, 2015).
When we talk about âstretchingâ and mobilization, we are talking about movements in a sub-maximum and painless range (or at least up to 2/10 on the pain scale) (Lubis & Lubis, 2013). Indeed, solicitation beyond the pain threshold would seem to have lower results than infra-painful mobilizations. This would be due to the mechanosensitive properties of fibroblasts (Diercks & Stevens, 2004).
As we mentioned earlier, in parallel with rehabilitation, a corticosteroid injection could be useful in order to short circuit this phase where pain dominates over stiffness (Sun et al., 2017), especially during the first 6 weeks (Cho et al., 2019), especially during the first 6 weeks (Cho et al., 2019). Based on the results of a recent systematic review, the authors recommend the use of infiltrations for patients with a frozen shoulder lasting less than 1 year, as they seem to have earlier benefits than other interventions; the authors point out that these benefits could last up to 6 months (Challoumas et al., 2020).
It will also be important to offer the patient exercises to do at home between physiotherapy sessions. These exercises can be done 1 to 2 times per day. However, there is no evidence for the optimal frequency, number of repetitions, or duration of exercises (Kelley et al., 2013). The therapist should therefore warn the patient that all these exercises should be performed painlessly (possibly a maximum pain of 2/10 on the EVA can be tolerated).
â
Secondly, when the patient presents more stiffness than pain, the therapist can then accentuate his techniques, for example, by extending the static stretching postures (Donatelli et al., 2014). The therapist will be able to seek greater levels of mobilization, more powerful stretches by seeking resistance (Srour & Nourissat, 2021).
Gradually, the decaptations and slips in the humeral head may be greater while respecting the patient's tolerance and irritability, especially at the beginning of this new phase in order to prevent him from falling back into a more painful phase.
Patient education should be maintained throughout rehabilitation: it is important to talk to him about how he will feel, about the progression of the pathology etc. Later in this phase it may be interesting to offer the patient sessions with shock waves given the high level of evidence recently reported in the literature.
â
In a similar way, this therapeutic progression could have been achieved by following the âStaged Approach for Rehabilitation Classification: Shoulder Disordersâ (McClure & Michener, 2015). Consequently, instead of addressing the two phases described above, this time it would be a question of following the irritability of the tissue (although these are two related concepts). Thus, by following a review of recent literature (Mertens et al., 2022), it would be possible to define treatments according to the three phases of irritability:
â
Special case of the recently operated patient (manipulation under anesthesia, arthrolysis, etc...)
In patients undergoing surgery (arthrolysis, manipulation under anesthesia), post-operative rehabilitation should be started as soon as possible in order to maintain the amplitudes obtained during the operation (Cho et al., 2019). This information correlates in particular with a study indicating that 96% of British physiotherapists interviewed considered that physiotherapy follow-up was necessary post-operatively and that it should be started before 72 hours post-operatively (Willmore et al., 2021).
According to some authors, pain control with anti-inflammatories and/or cryotherapy is essential during the 2-3 post-operative weeks to abolish pain. Likewise, a structured physiotherapy follow-up must be put in place for 4 to 6 months in order to maintain the amplitudes. This follow-up should include passive and/or active joint mobilizations as well as exercises to strengthen the rotator cuff, scapular muscles and CORE muscles (Pandey & Madi, 2021). An independent stretching program to be performed at home 2-3 times a day should be offered to patients (Cho et al., 2019).
ââ
Examples of exercises
Phase 1: inflammatory phase/painful phase
â Phase 2: stiffness phase
â
âPhase 3: recovery phase
â
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