Adhesive capsulitis of the shoulder


Also known as frozen shoulder.

A painful and disabling disorder in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing chronic pain.

Associated pain is usually constant, worse at night, and with cold weather.

Various movements or contacts can provoke episodes of pain and cramping.

It is thought to be caused by injury or trauma to the area and may have an autoimmune component.

Risk factors for frozen shoulder include: seizures, diabetes mellitus, stroke, accidents, lung disease, connective tissue diseases, thyroid disease, rheumatoid arthritis, and heart disease.

The incidence of adhesive capsulitis is approximately 3 percent in the general population, but because of misdiagnosis the disease is much less common than previously thought.

Occurrence is rare in children and people under 40.

Incidence peaks between 40 and 70 years of age.

In its idiopathic form, the condition is much more common in women than in men.

70% of patients are women aged 40–60.

More frequent in diabetic patients and is more severe and more protracted than in the non-diabetic population.

Damage to the shoulder or arm by injury or surgery may cause blood flow damage or the capsule to tighten from reduced use during recovery.

It is a possible adverse effect of some forms of highly active antiretroviral therapy, and can occur after breast and lung surgery.

Treatment consists of physical therapy, occupational therapy, medication, massage therapy, hydrodilatation or surgery.

Treatments may be painful.

Manipulation may require anesthesia to break up adhesions and scar tissue to help restore some range of motion in the shoulder joint.

Controlling pain and inflammation with analgesics and NSAIDs can be achieved.

Patients usually experience severe pain and sleep deprivation for prolonged periods.

Pain that gets worse when lying still and restricted movement/positions.

When pain is chronic the condition can lead to depression, neck and back discomfort, and weight loss due to long-term lack of deep sleep.

It is sometimes caused by injury, leading to lack of use due to pain.

Often arises spontaneously with no obvious preceding trigger factor.

Difficulty in concentrating, working, or performing daily life activities may occur.

The process usually resolves over time without surgery.

It leads to shoulder movement restriction, with progressive loss of both active and passive range of motion.

Rheumatic disease and shoulder surgery can also cause pain and limitation similar to frozen shoulder.

With adhesive capsulitis there is a lack of synovial fluid, which lubricates the gap between the humerus and the socket in the shoulder blade.

With a frozen shoulder the capsule thickens, swells, and tightens due to bands of adhesions that have form inside the capsule.

With less room in the joint for the humerus, movement of the shoulder is stiff and painful.

Simple movements, such as raising the arm, become difficult or impossible.

The most severely inhibited movement is the external rotation of the shoulder.

Stiffness and pain often worsen at night.

Pain due to frozen shoulder is usually dull or aching.

Pain can be worsened with attempted motion, or if bumped.

Frozen shoulder can be diagnosed if limits to the active range of motion are the same or almost the same as the limits to the passive range of motion.

Rarely an arthrogram or an MRI scan may be needed to confirm the diagnosis.

The normal course of a frozen shoulder has three stages:

Stage one: The freezing or painful stage.

Stage one may last from six weeks to nine months.

Stage one patients experience a slow onset of pain.

With increasing pain the shoulder loses motion.

Stage two: The adhesive stage is marked by a slow improvement in pain but the stiffness remains.

This stage generally lasts from four to nine months.

Stage three: The thawing or recovery, when shoulder motion slowly returns toward normal, and generally lasts from 5 to 26 months.

Imaging features of adhesive capsulitis can be identified on non-contrast MRI, though MR arthrography and invasive arthroscopy are more accurate in diagnosis.

Ultrasound and MRI can assess the coracohumeral ligament, with a width of greater than 3 mm being 60% sensitive and 95% specific for the diagnosis.

It may be associated with edema at the rotator interval, a space in the shoulder joint normally containing fat between the supraspinatus and subscapularis tendons, medial to the rotator cuff, and fibrosis and thickening as well.

Ultrasound associated findings with adhesive capsulitis is hypoechoic material, that may demonstrate increased vascularity surrounding the long head of the biceps tendon at the rotator interval, reflecting fibrosis.

Management is that of restoring joint movement and reducing shoulder pain, involving medications, physical therapy, and/or surgical intervention.

There is no strong evidence to favor any particular approach.

Medications used include NSAIDs, and corticosteroids are used in some cases either through local injection or systemically.

Manual therapy with massage therapy and daily extensive stretching may be employed.

If conservative measures are unsuccessful, manipulation of the shoulder under general anesthesia to break up the adhesions is sometimes used.

Arthroscopic surgery to cut the adhesions may be indicated in prolonged and severe cases.

Supervised neglect has a better outcome than intense physical therapy.

Supervised neglect refers to home exercises, pendulum exercises and active exercises within the painless range.

Intense physical therapy with passive stretching and manual mobilization together with exercises beyond the pain threshold.

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