High Yield Topics

Adhesive Capsulitis

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Ovid: 5-Minute Sports Medicine Consult, The


Adhesive Capsulitis
Yvonne Chow
Natasha Harrison
Rahul Kapur
Basics
Description
  • Commonly known as “frozen shoulder”
  • Painful restriction of glenohumeral joint range of motion
  • Caused by thickening and contraction of shoulder capsule
  • Classified into 2 categories:
    • Primary, which has an insidious idiopathic onset with no precipitating event
    • Secondary, which follows trauma, immobilization, or underlying systemic illness
Epidemiology
  • Slight predominance in females (1.4:1)
  • Mean age of onset is ∼55 yrs of age.
  • 15% experience bilateral disease.
Prevalence
2–3% of the general population; prevalence is 11% in patients with diabetes mellitus.
Risk Factors
  • Shoulder immobilization increases risk by 5–9× over the general population.
  • Diabetes mellitus: 40% lifetime risk in type 1 diabetics
  • Hyperthyroidism
  • Hypertriglyceridemia
  • Female gender
  • Age >40 yrs old
General Prevention
Avoidance of prolonged shoulder immobilization
Etiology
  • Exact pathophysiology of condition is unclear.
  • Increasing evidence suggests the process involves synovial inflammation with subsequent reactive fibrosis.
  • Initial synovial inflammation causes pain.
  • Resultant capsular fibrosis restricts range of motion (ROM).
  • Generally idiopathic
  • Can result from period of shoulder immobilization
  • Rarely, also arises from clinically significant trauma to shoulder, cervical radiculopathy, brachial plexus pathology, or rotator cuff tendonitis
  • Autoimmune theory of disease: Microvascular disease causes abnormal collagen repair, leading to capsular fibrosis.
Commonly Associated Conditions
  • Diabetes
  • Hyperthyroidism
  • Hypertriglyceridemia
  • Cervical spondylosis
Diagnosis
History
  • Progressive shoulder pain over weeks to mos. Patients will tend to have symptoms of pain and stiffness for weeks to months prior to presentation to a physician.
  • Pain worse with any shoulder movement, both active and passive. Pain is worse at night and may interfere with sleep. Pain usually is present in the region of the deltoid, but also may radiate into the upper arm and neck regions.
  • Common functional impairments include difficulty dressing, combing one's hair, reaching into one's back pocket for a wallet, or fastening a brassiere.
  • A careful medical history to exclude associated conditions should be conducted.
  • 3 clinical phases:
    • Phase 1: Painful phase, insidious onset of nocturnal pain, progresses to pain at rest, no restriction of ROM, may last 2–9 mos
    • Phase 2: Frozen or adhesive phase, progressive limitation of ROM in all directions, lasts 3–9 mos or longer
    • Phase 3: Thawing or regressive phase, symptoms gradually improve over 12–24 mos

P.19


Physical Exam
  • The hallmark of adhesive capsulitis is a decreased glenohumeral range of motion associated with pain. The loss of motion occurs earliest in external rotation, but later in the disease course, all ranges of motion are affected.
  • Observation usually reveals limited use of the limb and lack of arm swing in walking.
  • Pain at extremes of ROM may be the only finding in the early phase. The greatest limitation is usually seen in external rotation initially. In later stages, all ranges of motion usually are limited. The loss of motion commonly occurs in the following order: external rotation → abduction → internal rotation → forward flexion
  • There is a limitation of both active and passive ROM.
  • Active ROM may show inverted scapulothoracic motion to compensate.
  • Impingement (Neer, Hawkins) and biceps tendinopathy (Speed's) maneuvers may be positive.
  • The scapula usually is elevated, laterally placed, and protracted. Wasting of the shoulder girdle muscles may be present due to disuse atrophy.
Diagnostic Tests & Interpretation
Lab
None indicated, but may consider thyroid-stimulating hormone, glucose, triglycerides if patient presents with bilateral symptoms or is <45 yrs of age.
Imaging
  • No imaging is indicated, as the diagnosis primarily is clinical.
  • Radiographs are useful to assess the presence of alternate diagnoses. No specific findings on radiographs correlating with a diagnosis of adhesive capsulitis have been reported, though there may be periarticular osteopenia as a result of disuse.
  • Arthrography has been described as sensitive in making the diagnosis where the joint capsule volume is decreased 5–10 mL in comparison to 25–30 mL in a normal joint. However, a loss of volume of the shoulder capsule is not always present, and the test carries risks that have led some authors to recommend avoiding its use in diagnosis.
  • MRI may reveal slight thickening in the joint capsule and the coracohumeral ligament.
Differential Diagnosis
  • Rotator cuff disease
  • Impingement syndrome
  • Biceps tendinopathy
  • Posterior shoulder dislocation
  • Arthritis/degenerative arthrosis of the glenohumeral joint
  • Cervical radiculopathy
  • Polymyalgia rheumatica
  • Fracture of the humerus or glenoid
  • Referred pain from the cervical spine, thorax, or abdomen
Treatment
  • A high rate of spontaneous recovery within 18–30 mos for this condition should be kept in mind when choosing treatment options. Treatment should be focused on relief of symptoms and optimization of ranges of motion.
  • NSAIDs can be used, if tolerated, to aid with pain control in the initial painful phase.
  • Distention with saline and steroid can reduce pain and improve ROM and function in the short-term. At 2 yrs of follow-up, distention was as effective as manipulation under anesthesia (MUA) without the risks associated with MUA.
  • Oral steroids also can provide short-term benefits in pain relief and improved ROM and function. However, oral steroids have side effects that limit the patient population for which they can be used.
  • Intra-articular corticosteroid injections have been shown to decrease pain, improve function, and increase ROM. Multiple injections have been shown to be beneficial, specifically up to 3 injections within a 16-wk period. There is a theoretical risk of weakening ligaments, tendons, and/or other capsular structures with repetitive cortisone injections though.
  • A program of therapeutic exercise comprising gentle range of motion exercises, stretching, and graded resistance training has been associated with increased range of motion and decreased pain. The program should be guided by the patient within the limits of his or her pain, and vigorous programs that increase symptoms should be avoided.
  • Suprascapular nerve blocks may decrease pain.
  • Manipulation under anesthesia is recommended if conservative measures fail.
  • Surgical capsular release also may be utilized for refractory cases.
Additional Reading
Buchbinder R, Green S, Youd JM, et al. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2008;(1):CD007005.
Buchbinder R, Green S, Youd JM, et al. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev. 2006:CD006189.
Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ. 2005;331:1453–1456.
Jacobs LG, Smith MG, Khan SA, et al. Manipulation or intra-articular steroids in the management of adhesive capsulitis of the shoulder? A prospective randomized trial. J Shoulder Elbow Surg. 2009;18:348–353.
Shah N, Lewis M. Shoulder adhesive capsulitis: systematic review of randomised trials using multiple corticosteroid injections. Br J Gen Pract. 2007;57:662–667.
Codes
ICD9
726.0 Adhesive capsulitis of shoulder


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