CPG Adhesive cap

Question 1

What is the hallmark clinical finding of adhesive capsulitis

Answer 1

lass of passive ROM, particularly ER with arm at the side and varying degrees of shoulder abduction
- theoretical evidence

Question 2

what are the risk factors associated with Acap

Answer 2

DM (men and women) and hypoThyroid disease (women), h/o duputren’s disease
- moderate evidence

Question 3

Acap is most prevalent in what populations

Answer 3

females general population, DM male (33%, females 26%), age 45-65 (peak 51-55), with history of contralateral Acap
- Moderate evidence

Question 4

How long does Acap typical take to resoluve

Answer 4

12-18 months

Question 5

what disability indexes have been validated for Acap

Answer 5

1. DASH
2. Shoulder and elbow surgeons shoulder sale (ASES)
3. Shoulder pain and disability index (SPADI)
   - Strong evidence

Question 6

Describe the role of corticosteroid injections in Acap

Answer 6

when combined with mobility and stretching exercises it is effective in providing short term pain relief (4-6 weeks) compared to exercise alone
- strong evidence

Question 7

What are the educational recommendations for Acap

Answer 7

1. understand the natural course of the disease
2. promote activity modification to encourage functional pain free motion
3. match intensity of stretching to patient current level of irritability
   - moderate evidence

Question 8

what modalities are recommend for Acap

Answer 8

Week evidence suggests short wave diathermy, US and estim when combined with stretching and joint mobs can help control symptoms

Question 9

What forms of treatment are recommend for Acap

Answer 9

• joint mobs weak evidence
• manipulation under anesthesia weak evidence
• stretching matched to stage of irritability moderate evidence

Question 10

how does the prevalence of shoulder pain compare to the prevalence of Acap in the general population

Answer 10

shoulder pain 2.4-26%

ACap 2-5.3%

Question 11

Subscapularis will restrict what motins

Answer 11

ER at 0

Question 12

Cadaver sides of Acap demonstrates what pathoanatomic features

Answer 12

Limitations of the proximal portions of the capsuloligamentous complex and subscap tendon

Question 13

what is rotator cuff interval

Answer 13

• triangular shaped tissue bridge between the anterior supraspinatus, upper subscapularis, upper biceps sulcus lateral ridge at the transverse humeral ligament
• composed of the superior GH lig and coracohumeral ligament

Question 14

what is the pathoanatomic origin of Acap

Answer 14

there is some debate with level IV data
- synovitis
- agniogeneisis with nerve in growth
This develops into capsiloligamentus fibrosis can contracture
- primarily involves rotator cuff interval, but can be the entire capsule

Question 15

What causes Acap

Answer 15

unkown

Question 16

Level IV evidence also suggest what risk factors

Answer 16

• prolonged immobilization
• MI
• trauma
• autoimmune disease

Question 17

describe the clinical course of Acap

Answer 17

4 stages

1. up to 3 months - sharp end range pain, ache at rest and difficulty sleeping. marked synovial irritation without contracture
2. 3-9 months - gradual loss of motion - aggressive synovitis with some ROM loss under anesthesia
3. 9-15 months - reduction of synovitis and resultant fibrosis
4. 15-24 months - pain reaction with gradual return of ROM

Question 18

What are the MSK clinical signs typically used to identify Acap

Answer 18

• shoulder pain longer than on e month
• sleep disturbance due to shoulder pain
• inability to lie on the affected side
• restricted in all AROM and PROM
• 50% reduction in ER and 25% reduction in at least 2 planes

Question 19

what factors are predictive of Manipulation for Acap

Answer 19

• prior rehab
• work comp claim
• pending litigation

Question 20

How does the course of recovery differ for function and pain with Acap

Answer 20

• Function and satisfaction tend to have full resolution

- pain and ROM loss can last much longer and does not follow the same recovery pattern as functional return

Question 21

what is the difference between primary and secondary Acap

Answer 21

1. primary has no associated health conditions

2. secondary is linked to a disease or pathology

Question 22

what are the subcategories of secondary Acap

Answer 22

1. systemic
2. extrinsic
3. intrinsic

Question 23

what are the conditions associated with systemic secondary Acap

Answer 23

1. DM

2. thyroid disease

Question 24

what are the conditions associated with extrinsic secondary Acap

Answer 24

1. CVA
2. intrathoracic conditions such as MI or COPD
3. intra-abdominal conditions
4. cerivcal disc disease
5. distal extremity fractures
6. self imposed immobilization

Question 25

what conditions are associated with intrinsic secondary Acap

Answer 25

things within the GH 1. RTC and bicep tendonopathies 2. AC and GH arthropathies 3. proximal humeral or scapular fractures

Question 26

describe the data surround cyriax capsular pattern

Answer 26

- Capsular pattern of ascending loss of ER, abd, IR | - Data shows there is a loss of ER at the side, abduction and IR greater than ER with arm abducted

Question 27

what the the Acap clinical practice guidelines

Answer 27

1. component 1 - Medical screening to determine if the person is appropriate for physical therapy 2. component 2 - differential evaluation for MSK impairment of body function (ICF) and associated tissue pathology (ICD) 3. component 3: diagnosis of tissue irritability level 4. component 4: interventional strategies

Question 28

What diagnostic classifications are suggested for the shoulder

Answer 28

1. shoulder pain and mobility deficits/Acap 2. shoulder stability and movement coordination impairments (dislocation, sprain strain) 3. shoulder pain and muscle power deficits and RTC syndrome

Question 29

how would your rule in/our the diagnostic classification of shoulder pain and mobility deficits

Answer 29

``` Rule in - age 40-65 - gradual one of progressive worsening of pain and ROM loss - ROM loss following ER at side, abduction and IR at 90 - restricted joint motions rule out - PROM normal - increase in rotation at 90 degree -ULTT produces symptoms - postive tinels ```

Question 30

How would you rule in/out the shoulder stability and movement coordination treatment classification

Answer 30

``` rule in - less than 40 - history of dislocation - excessive GH accessory motion - end range apprehension rule out - no dislocation history - global GH motion loss - no apprehension at end ragne ```

Question 31

how would you rule in/out muscle power deficit RTC syndrome

Answer 31

``` Rule in - symptoms increase with repetitive motion - mid range catching - pain production with MMT - RTC weakness rule out - pain free resistance testing - normal RTC strength - significant PROM loss ```

Question 32

what recommendations are made regarding classification of tissue irritability

Answer 32

``` High - pain greater than 7 - consistent night or resting pain - high self reported disability - pain before end ranges of PROM or AROM - AROM sign less than PROM moderate - 4-6 pain - intermittent night or resting pain - moderate self report disability - pain at end ranges of motion - AROM similar to PROM low - pain less than 3 - no night or rest pain - minimal self reported disability - pain with ROM over-pressure - AROM and PROM the same ```

Question 33

What type of imaging studies can help with differential diagnosis of Acap

Answer 33

- Normal X-ray - arthrograph showing joint capsule capacity of less then 10-12mL - MRI- impairments of capsule and RTC interval as well as thickened coracohumeral ligaments and smaller axillary recess volume - US - fiborvasular inflammatory soft tissue changes of the RTC interval and increased thickness of the coracohumeral ligament (3mm to 1.3mm)

Question 34

what is the normal thickness of the coracohumeral ligament

Answer 34

1.33 mm

Question 35

what recommendations are made regarding classification of tissue irritability

Answer 35

``` High - pain greater than 7 - consistent night or resting pain - high self reported disability - pain before end ranges of PROM or AROM - AROM sign less than PROM moderate - 4-6 pain - intermittent night or resting pain - moderate self report disability - pain at end ranges of motion - AROM similar to PROM low - pain less than 3 - no night or rest pain - minimal self reported disability - pain with ROM over-pressure - AROM and PROM the same ```

Question 36

What type of imaging studies can help with differential diagnosis of Acap

Answer 36

- Normal X-ray - arthrograph showing joint capsule capacity of less then 10-12mL - MRI- impairments of capsule and RTC interval as well as thickened coracohumeral ligaments and smaller axillary recess volume - US - fiborvasular inflammatory soft tissue changes of the RTC interval and increased thickness of the coracohumeral ligament (3mm to 1.3mm)

Question 37

what is the normal thickness of the coracohumeral ligament

Answer 37

1.33 mm