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2 Case Study 2
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5 Codman’s Paradox in adhesive capsulitis 5
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ABSTRACT
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Background: Even though, it is said that adhesive capsulitis is a self‑limiting condition, many subjects remain with long‑term sequelae.
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Codman’s paradox is commonly used in manipulation under anesthesia technique for adhesive capsulitis of shoulder, which composes of a
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specific pattern of motion at the shoulder joint leading to an indirect humeral rotation without placing a rotational torque on the humerus. In this
11 case study, Codman’s paradox movement was modified and performed within pain tolerable range and without anesthesia in a subject with 11
12 adhesive capsulitis. 12
13 Aim and Objective: This case study analyses the effect of modified Codman’s paradox movement in a 50‑year‑old male diagnosed with 13
14 symptoms of adhesive capsulitis for more than 6 months. 14
15 Materials and Methods: A single case study design was used. The study duration was 4 weeks. Baseline and posttest outcomes measures 15
16 of shoulder range of motion (ROM) (flexion, extension, abduction, external rotation, and internal rotation) were measured using a universal 16
17 goniometer and Shoulder Pain and Disability Index (SPADI) questionnaire. 17
18 Results: Posttest measures of numerical pain rating scale, shoulder ROM and SPADI showed improvement, proving that modified Codman’s 18
19 paradox is effective in adhesive capsulitis. 19
20 Conclusion: This study result concludes that modified Codman’s paradox is effective in improving shoulder ROM among subjects with 20
21 adhesive capsulitis. 21
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23 Keywords: Adhesive capsulitis, Codman’s paradox, Shoulder Pain and Disability Index 23
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AQ2 Uniqueness described as having three sequential phases: a painful stage, 26
27 Simulating Codman’s paradox movement (without a freezing stage, and a thawing or recovery stage. Pain and 27
28 manipulation under anesthesia) in conservative management limited ROM can occur in all phases of adhesive capsulitis, 28
29 of adhesive capsulitis is a new concept and not reported in 29
30 the literature. Hariharasudhan Ravichandran, 30
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31 Balamurugan Janakiraman1, Berihu Fisseha, 31
32 Subramanian Sundaram2, Asmare Yitayeh Gelaw1 32
INTRODUCTION
Department of Physiotherapy, School of Medicine, College of
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Health Sciences and Ayder Comprehansive Specialized Hospital,
34 The shoulder is the site of many painful conditions. 34
Mekelle University, Mekelle, 1Department of Physiotherapy, School
35 The shoulder is a unique anatomical structure with an 35
of Medicine, College of Medicine and Health Sciences, University
36 extraordinary range of motion (ROM) that allows us to of Gondar, Gondar, Ethiopia, 2Department of Physiotherapy, Sree
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37 interact with our environment.[1] Adhesive capsulitis is Balaji College of Physiotherapy, Chennai, Tamil Nadu, India 37
38 reported to affect 2%–5% of the general population[2] and 38
39 Address for correspondence: Dr. Hariharasudhan 39
has been reported in 19% of type II diabetes subjects.[3] Ravichandran,
40 Adhesive capsulitis hinders the function of shoulder which Department of Physsiotherapy, Sree Balaji College of 40
41 Physiotherapy, Chennai, Tamil Nadu, India. 41
is crucial in many activities of daily living.[4] It has been E‑mail: hrkums63@gmail.com
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48 DOI:
How to cite this article: Ravichandran H, Janakiraman B, Fisseha B, 48
Sundaram S, Yitayeh A. Effectiveness of modified Codman’s paradox
49 10.4103/sjsm.sjsm_33_17 movement in the management of adhesive capsulitis: A case study.
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50 Saudi J Sports Med 2017;XX:XX-XX. 50
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© 2017 Saudi Journal of Sports Medicine | Published by Wolters Kluwer - Medknow 1
 Ravichandran, et al.: Posterolateral corner injuries rehabilitation of knee

1 which often does not follow a stepwise course. Pain and On examination, he had no history of trauma inciting this 1
2 decreased ROM can persist for one to 2 years,[5,6] and up present complaint. No history of radiating pain and no other 2
3 to 10% of patients never recover full ROM.[7] The diagnosis joint pain or stiffness. He had no history of previous inpatient 3
4 is usually clinical, although imaging can help rule out hospitalizations. Mr. Settu had an endomorphic built with 4
5 other conditions. Several treatment options are commonly protracted shoulders. On examination, both shoulder were 5
6 used, but few have high‑level evidence to support them. at same levels, no swelling, or redness. On palpation, mild 6
7 Many treatment options for adhesive capsulitis have been tenderness of grade II present around the joint line. ROM was 7
8 described in the literature. One of the main goals of all the measured using universal goniometer, and it restricted up 8
9 treatment is to restore shoulder function. Manipulation to 95° of shoulder flexion, 80° of abduction, 15° of external 9
10 under anesthesia is considered as the last option in rotation, and 60° of internal rotation (tested in arm parallel 10
11 conservative management. It must be emphasized that even to trunk). Right scapular motion was restricted in upward 11
12 after manipulation under anesthesia, a regular supervised rotation. Left non affected shoulder and scapula motion 12
13 physiotherapy is critical to ensure a mobile painless was normal. Passive accessory movements of glenohumeral 13
14 shoulder otherwise significant stiffness quickly returns.[8] posterior, inferior and lateral glides were restricted. There is 14
15 Codman’s manipulation is the technique widely used during no distal neurovascular deficits. The pain was aggravated by 15
16 manipulation under anesthesia. Codman’s manipulation any attempt to do overhead activities and relieved by rest, 16
17 includes three consecutive 90° rotations called elevation, hot packs, or medications. In numeric pain rating scale, pain 17
18 swing and descending movements. These movements lead at end ranges in all planes was 8/10. His ADL assessment 18
19 to the indirect humeral rotation without placing a rotational 19
revealed that he had difficulty while bathing (inability to
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torque on the humerus, thereby reducing fracture risk during reach a hand behind back or neck), wearing T‑shirt, donning
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manipulation.[9] a belt, combing, tucking the shirt, etc.
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However, there is lack of evidence of the effectiveness of Mr. Settu was advised to continue using his right upper
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simulating Codman’s paradox movement without anesthesia extremity with his customary activities of daily living.
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among subjects with Adhesive capsulitis. This case study
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aims to investigate the effectiveness of modified Codman’s Study protocol
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paradox movement in a subject with adhesive capsulitis. A single case study (A‑B‑A) design was used. The study
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protocol is divided into three phases. The first phase consists
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CASE REPORT of baseline assessment of the right shoulder measured
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using numerical pain rating scale, shoulder ROMs (flexion,
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A 50‑year‑old man Mr. Settu presented to the physiotherapy abduction, extension, external rotation, and internal rotation)
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department with a history of pain and stiffness in the right and shoulder pain and disability index (SPADI).
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shoulder for the past 6 months. He was a ward assistant
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in a hospital by profession. He complains of pain that The second phase is the intervention phase in which, modified
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was aggravated by any activities that require overhead Codman’s paradox movement was used. In this method, Mr.
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arm movement. Initially, he had pain and stiffness at Settu was positioned in supine lying in a treatment couch
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38 end ranges in overhead activities and gradually stiffness with adequate exposure of the right shoulder. He was advised 38
39 and pain has worsened. At present, he was unable to to completely relax his shoulder during the intervention. 39
40 lift his arm above shoulder level. He was a known case His upper limb was positioned parallel to trunk with palm 40
41 of type II diabetes mellitus for the past 7 years and on facing medically and thumb pointing anteriorly, his arm was 41
42 medications (ORAL HYPOGLYCAEMIC AGENTS). For the elevated passively up to pain tolerable ROM in the plane of 42
43 present complaint of the right shoulder pain, he sought flexion and when the pain reaches maximum tolerable, the 43
44 private orthopedician’s opinion 3 months ago, X‑ray and arm is abducted and descended to place parallel to trunk with 44
45 laboratory investigations (thyroid function tests) were done palm facing outward and thumb pointing posteriorly. This 45
46 and found to be normal without any abnormalities. He was movement pattern was repeated for 5 times per set, 3 sets 46
47 managed with analgesics and referred to a local physiotherapy in a session, and 5 sessions in a week. The intervention was 47
48 clinic to undergo wax bath for 10 days followed by shoulder provided for 2 weeks. Hot pack fermentation provided to the 48
49 exercises. The pain was relieved by 30% during the medication shoulder before and after the intervention. 49
50 period and recurred once stopping the drugs. He regularly 50
51 does shoulder pendular swinging, wall ladder exercise and Third phase is the post‑intervention phase. Post‑intervention 51
52 active assisted shoulder ROM in all planes. measures of numerical pain rating scale, shoulder 52
Saudi Journal of Sports Medicine / Volume XX / Issue XX / Month 2017
 Ravichandran, et al.: Posterolateral corner injuries rehabilitation of knee

1 ROMs (flexion, abduction, extension, external rotation, and CONCLUSION 1

2 internal rotation), and SPADI were recorded. 2
3 Modified Codman’s paradox movement performed in this 3
4 RESULTS case study in an effort to increase shoulder joint mobility 4
5 in adhesive capsulitis have shown significant improvement 5
6 Mr. Settu had improved ROM with a slight reduction in in posttreatment period. Further studies in the form of RCT 6
7 pain. Numerical pain rating score was 5/10 after 2 weeks are warranted to compare the therapeutic effects of this 7
8 of intervention. Flexion, abduction and external rotation movement with other treatment regimens. 8
9 have improved with the intervention. SPADI was improved 9
10 from 64.61% (baseline) to 30% in the postintervention Acknowledgment 10
11 period [Table 1]. This case study proves that modified The authors would like to acknowledge their gratitude to 11
12 Codman’s paradox movement pattern is effective in and Dr. Clement joseph (MS Ortho) full fledge to complete 12
13 improving outcomes among subjects with adhesive this study. We are thankful to all the therapist and referral 13
14 capsulitis. physicians of Global hospitals and health city for their 14
15 support. We also wish to express our gratitude for our family 15
16 DISCUSSION members and friends. 16
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18 Financial support and sponsorship 18
This case study was designed to determine the use of
19 Nil. 19
modified Codman’s paradox movement in improving shoulder
20 ROM, function and pain over 2 weeks’ period. The result 20
21 Conflicts of interest 21
of this case study supports modified Codman’s paradox
22 There are no conflicts of interest. 22
movement in improving shoulder ROM in adhesive capsulitis.
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