Adhesive capsulitis in hemiplegic shoulder

🧠 Case Scenario: Frozen Shoulder in a 42-Year-Old Post-Stroke Patient (Hemiplegic Side)

📌 Patient Profile

  • Name: Mr. R. (initials only)

  • Age: 42 years

  • Gender: Male

  • Occupation: School Accountant

  • Medical History: Right-sided ischemic stroke 6 months ago → left hemiplegia

  • Lifestyle: Dependent for dressing & grooming, sedentary since stroke

  • Current Complaint: Severe stiffness and pain in left shoulder (hemiplegic side)

📌 Presenting Complaints

  • Shoulder pain worsens at night and with passive movement

  • Difficulty in passive dressing and hygiene

  • Unable to reach overhead with affected arm

  • Pain intensity: VAS 8/10 on movement, 5/10 at rest

  • Caregiver reports “frozen” arm while assisting in ADLs

📌 Clinical Examination

🔹 Inspection

  • Hemiplegic posture: shoulder adduction, internal rotation

  • Muscle wasting (deltoid, supraspinatus)

  • Mild subluxation noted in glenohumeral joint

🔹 Palpation

  • Spasm and tightness in pectoralis major, subscapularis, and upper trapezius

  • Tenderness at anterior capsule

🔹 Range of Motion (ROM)

  • Flexion: 60° (painful)

  • Abduction: 45°

  • External Rotation: 10°

  • Internal Rotation: 30°

🔹 Neurological Considerations

  • Spasticity in biceps and pectoralis

  • Decreased voluntary motor control

  • Weak scapular stabilizers

Diagnosis: Adhesive Capsulitis (Frozen Shoulder) of hemiplegic side post-stroke

📌 Pathophysiology

  • After stroke, shoulder immobility + abnormal tone (spasticity) → capsule tightens → frozen shoulder develops.

  • Muscle weakness and subluxation worsen stiffness.

  • Pain + spasticity creates a vicious cycle of non-use → contracture → frozen shoulder.

📌 Physiotherapy Management Plan

🔹 Stage 1: Painful (Freezing Stage)

Goals: Pain control, maintain mobility, prevent contracture

  • Modalities:

    • Moist heat before stretching

    • TENS for shoulder pain

    • Proper arm positioning in bed (arm supported with pillows)

  • Exercises:

    • Gentle pendulum swings (assisted by caregiver)

    • Passive & active-assisted ROM (flexion, abduction, ER)

    • Scapular mobilization (protraction, retraction)

    • Gentle weight-bearing through affected arm (on table, quadruped if tolerated)

🔹 Stage 2: Frozen Stage

Goals: Increase ROM, reduce spasticity, improve shoulder function

  • Manual Therapy:

    • Joint mobilizations (Grade II–III, pain-free)

    • Soft tissue release for pectoralis & subscapularis

    • Positioning strategies to avoid abnormal postures

  • Exercises:

    • Pulleys and stick-assisted ROM

    • Rhythmic rotation for tone inhibition

    • Weight-bearing on affected arm (sitting, leaning forward)

    • Mirror therapy for motor relearning

  • Adjunct:

    • Functional electrical stimulation (FES) to deltoid & supraspinatus

    • Constraint-induced therapy (if voluntary control exists)

🔹 Stage 3: Recovery (Thawing Stage)

Goals: Restore mobility, strengthen shoulder, integrate into ADLs

  • Strengthening:

    • Theraband scapular retraction & external rotation

    • Closed chain exercises (wall push-ups, ball rolling on wall)

    • Active reaching in multiple directions

  • Functional Training:

    • Dressing, grooming with affected arm

    • Bimanual tasks (holding objects with both hands)

    • Overhead reaching with progressive resistance

  • Patient & Caregiver Education:

    • Avoid pulling arm during transfers

    • Support arm in sling when walking

    • Daily ROM exercises at home

📌 Progress Notes (Expected)

  • Week 2–4: Pain decreases (VAS 5/10), ROM improves slightly

  • Week 6–8: Flexion 90°, abduction 70°, better tolerance in dressing

  • Month 3: Functional use of arm in simple ADLs

  • Month 6: Near-functional ROM, improved independence

📌 Discussion & Learning Points

  • Post-stroke frozen shoulder is multifactorial → immobility, spasticity, weakness, and subluxation.

  • Physiotherapy must focus on tone management + mobility + functional training.

  • Caregiver training is crucial to prevent shoulder injuries during transfers.

  • Early mobilization post-stroke significantly reduces risk of adhesive capsulitis.

📌 Key Takeaway for DPT Students

“Frozen shoulder in post-stroke patients is not just a musculoskeletal issue — it’s a neuro-musculoskeletal complication requiring a combined approach of tone management, ROM restoration, and functional rehabilitation.”

❓ Frequently Asked Questions (FAQs)

1. What is frozen shoulder in stroke patients?

Frozen shoulder, also called adhesive capsulitis, is a painful condition where the shoulder joint becomes stiff and loses mobility. In stroke patients, it often develops on the paralyzed (hemiplegic) side due to immobility, poor positioning, and muscle imbalance.

2. Why do stroke patients develop frozen shoulder?

Stroke patients are at risk of frozen shoulder because:

  • Lack of active movement in the affected arm

  • Prolonged immobilization in bed or wheelchair

  • Improper positioning of the shoulder joint

  • Spasticity or muscle tightness

  • Poor handling during transfers or daily care

3. How can frozen shoulder be prevented after a stroke?

  • Encourage early gentle mobilization of the affected arm

  • Use proper positioning techniques in bed and while sitting

  • Perform passive range of motion (ROM) exercises daily

  • Support the shoulder during transfers with a sling or arm support

  • Educate caregivers to avoid pulling the weak arm

4. What is the physiotherapy treatment for frozen shoulder after stroke?

Physiotherapy is the main treatment and may include:

  • Passive and assisted ROM exercises to maintain mobility

  • Shoulder mobilization techniques to reduce stiffness

  • Heat therapy or TENS for pain relief

  • Strengthening exercises for surrounding muscles

  • Spasticity management (stretching, relaxation techniques)

  • Functional training to restore daily activities

5. Can frozen shoulder heal completely in stroke patients?

Recovery depends on the severity of stroke and joint stiffness. With early intervention, regular exercises, and physiotherapy, frozen shoulder can significantly improve, but some patients may continue to have mild stiffness.

6. How long does it take to recover from frozen shoulder after stroke?

Recovery time varies:

  • Mild cases: 3–6 months with consistent therapy

  • Severe cases: May take 12–18 months or longer

  • Consistency in therapy is the key to faster recovery

7. Should stroke patients with frozen shoulder do exercises at home?

Yes ✅ Home exercises are very important. Patients (or caregivers) can perform:

  • Gentle pendulum swings

  • Passive stretching of the arm

  • Towel-assisted stretches

  • Wall climbing exercises (with supervision)

However, exercises should be done under the guidance of a physiotherapist to avoid injury.


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