1740
Also known as frozen shoulder.
Adhesive capsulitis newly affects approximately 0.75% to 5.0% percent of people a year.
Frequency about 4% of population.
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.
The loss of the ability to move the shoulder, both voluntarily and by others, occurs in multiple directions.
The shoulder itself does not generally hurt significantly when touched.
Muscle loss around the shoulder may also occur.
Onset is gradual over weeks to months.
Usual onset is an 40 to 60 years of age.
Causes: Often unknown, prior shoulder injury.
Complications of frozen shoulder can include fracture of the humerus or biceps tendon rupture.
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.
Differential diagnosis
Pinched nerve, autoimmune disease, biceps tendinopathy, osteoarthritis, rotator cuff tear, cancer, bursitis
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.
Its underlying mechanism involves inflammation and scarring.
Adhesive capsulitis (AC) has been linked to diabetes and hypothyroidism.
Diagnosis is generally based on a symptoms and a physical exam.
The diagnosis may be supported by an MRI examination.
Rarely an arthrogram or an MRI scan may be needed to confirm the diagnosis.
The symptoms of primary frozen shoulder has three or four stages.
A prodromal stage is described that can be present up to three months prior to the shoulder freezing: sharp pain at end ranges of motion, achy pain at rest, and sleep disturbances.
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.
Physical exam findings in adhesive capsulitis includes restricted range of motion in all planes of movement in both active and passive range of motion.
This contrasts with conditions such as shoulder impingement syndrome or rotator cuff tendinitis: the active range of motion is restricted but passive range of motion is normal.
Some exam maneuvers of the shoulder may be impossible to achieve due to pain
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.
Factors associated with higher risk of AC : injury or surgery leading to prolonged immobility, and systemic diseases, such as COVID-19, diabetes mellitus, stroke, lung disease, connective tissue diseases, thyroid disease, heart disease, autoimmune disease, and Dupuytren’s contracture.
Both type 1 diabetes and type 2 diabetes are risk factors for the condition.
Primary adhesive capsulitis, also known as idiopathic adhesive capsulitis, occurs with no known trigger.
Idiopathic adhesive capsulitis is more likely to develop in the non-dominant arm.
Secondary AS: develops after an injury or surgery to the shoulder.
Pathophysiology is accepted to have both inflammatory and fibrotic components.
The hardening of the shoulder joint capsule is central to the disease process.
The hardening of the shoulder joint capsule is the result of scar tissue around the joint capsule.
A reduction in synovial fluid of the shoulder joint capsule may occur.
The synovial fluid normally helps the shoulder joint, a ball and socket joint, move by lubricating the gap between the humerus and the socket in the shoulder blade.
In the painful stage 1there are inflammatory cytokines in the joint fluid.
Thickening of the coracohumeral ligament, which forms the roof of the rotator cuff is a primary limiting factor in external rotation.
The coracohumeral ligament limits internal rotation considering its connection to the supraspinatus and subscapular tendons.
As adhesive capsulitis progress, the glenohumeral capsule begins to thicken contracting the capsule itself and becomes the main reason the range of motion will be restricted in all planes of motion.
Adhesive capsulitis can be diagnosed by history and physical exam, and
It is often a diagnosis of exclusion, as other causes of shoulder pain, and stiffness must first be ruled out.
Adhesive capsulitis can be diagnosed if limits of the active range of motion are the same or similar to the limits to the passive range of motion.
The movement that is most severely inhibited is external rotation of the shoulder.
Imaging studies are not required for diagnosis.
Imaging studies may be used to rule out other causes of pain.
Radiographs are often normal
Findings of adhesive capsulitis can be seen on ultrasound or non-contrast MRI.
Ultrasound and MRI can help in diagnosis by assessing the coracohumeral ligament, with a width of greater than 3 mm being 60% sensitive and 95% specific for the diagnosis on ultrasound and MRI
Adhesive capsulitis of the shoulder characteristically shows fibrosis and thickening at the axillary pouch best seen as a dark signal on T1 sequences with edema and inflammation on T2 sequences.
Ultrasound associated findings with adhesive capsulitis is hypoechoic material surrounding the long head of the biceps tendonreflecting fibrosis.
Such hypoechoic changes. may demonstrate increased vascularity with Doppler ultrasound.
Grey-scale ultrasound has a role in timely diagnosis of adhesive capsulitis due to its high sensitivity and specificity.
Ultrasound can demonstrate thickening in the coracohumeral ligament, inferior capsule/ axillary recess capsule, rotator interval abnormality, and restriction in range of motion in the shoulder.
The range of motion is prohibited due to scapulohumeral kinematic changes occurring in the shoulder joint, restricting anterior and posterior tilting, downward rotation and depression as well as external rotation.
Such restrictions lead the scapula to be excessively upwardly rotated.
Management of this disorder: restoring joint movement and reducing shoulder pain, use of medications, acupuncture therapy, or surgery.
The main treatment for adhesive capsulitis is a trial of conservative therapies, including analgesia, exercise, oral nonsteroidal anti-inflammation drugs, and intra-articular corticosteroid injections.
NSAIDs can be used for pain control.
Corticosteroids are used in some cases either through local injection or systemically.
In the short term, intra-articular corticosteroid injections are more effective in pain alleviation, butit is not long-lasting.
Intra-articular corticosteroid injections improved passive range of motion.
Steroid injections compared to physical therapy have a similar effect in improving shoulder function and decreasing pain, but benefits appear to be short-term.
Intracorticosteroid early in individuals with frozen shoulder who have had it for less than a year had a better prognosis.
Oral corticosteroids should not be used consistently to treat adhesive capsulitis.
Manipulation of the shoulder under general anesthesia to break up the adhesions is sometimes used.
Arthrographic distension may play a positive role in reducing pain and improve range of movement and function.
Arthroscopic surgery to cut the adhesions/capsular release, may be indicated in prolonged and severe cases.
Adhesive capsulitis may respond to open release surgery, allowing the surgeon to find and correct the underlying cause of restricted glenohumeral movement such as contracture of coracohumeral ligament and rotator interval.
Extracorporeal shock wave therapy (ESWT) combined with shoulder stretching and strengthening exercises may reduce pain levels and improving range of motion and functioning.
Laser therapy was also found to have these similar effects.
Prognosis
Most cases of adhesive capsulitis are self limiting, but may take 1 to 3 years to fully resolve.
Pain and stiffness may not completely resolve in 20 to 50 per cent of affected people.
AC rates are higher in people with diabetes (10–46%).
Following breast surgery, some known complications include loss of shoulder range of motion (ROM) and reduced functional mobility in the involved arm.
Occurrence is rare in children and people under 40. with the highest prevalence between 40 and 70 years of age.
The condition is more common in women than in men (70% of patients are women aged 40–60).
People with diabetes, stroke, lung disease, rheumatoid arthritis, or heart disease are at a higher risk for frozen shoulder.
Symptoms in people with diabetes may be more protracted than in the non-diabetic population.
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.