Adhesive Capsulitis (Frozen Shoulder)
Adhesive capsulitis is characterized by painful, gradual loss of active and passive shoulder motion resulting from fibrosis and contracture of the joint capsule.
- Peri-arthritis scapulo-humeralewas the initial term suggested by Duplay
- The term Frozen shoulder was coined by Codman
- The term Adhesive Capsulitis, coined by Neviaser, is more precise as it expresses the true pathology of this entity.
Two Types (Lundberg)
- Primary (no inciting event, no abnormal examination findings)- idiopathic
- Secondary (inciting event present): intrinsic, extrinsic and systemic causes
- Intrinsic: Shoulder fracture, tendonitis, rotator cuff tear, degenerative joint disease
- Extrinsic: Neurological radiculopathy, head trauma, complex regional pain
syndrome, Parkinson, cardiovascular accident, humeral fractures
- Systemic: Diabetes, thyroid disease, myositis/polymyalgia rheumatic
Adhesive capsulitis per se should be used for primary or idiopathic variety as secondary type has different pathogenesis which may neither include inflammation of capsule nor formation of adhesions.
- Inflammatory process leading to fibrosis in joint capsule
- Cause of inflammation remains unknown
- Thickened, tight glenohumoral joint with obliteration of axillary pouch
- Contracture of the rotator cuff interval
- Reduction in joint volume (5-10 ml as compared to 28-35 ml in normal joint)
- Biopsy of capsule shows chronic inflammatory infiltrate, absence of synovial lining, and moderate to extensive subsynovial fibrosis. Perivascular lymphocytic reactions are noted as well.
- Increased levels of transforming growth factor-? and other profibrotic cytokines
- Commoner in females of 40-60 years age, affects non-dominant side more frequently and is more common in persons in sedentary vocations
- Risk Factors: Cardiovascular disease, thyroid dysfunction, breast cancer treatment, cerebrovascular accident, , myocardial infarction, Diabetes
- Diabetes carries risks of significantly worse prognosis, greater need for surgery, and suboptimal results
- PAIN: Gradual onset pain of several months duration. Pain is typically referred to the origin of deltoid and may be present at night
- STIFFNESS: accompanies or rarely precedes pain and worsens with disease progression. Internal rotation is lost initially, then flexion and ext. rotation
Primary frozen shoulder goes through 3 phases:
Phase I—characterised by Pain (freezing phase)
Phase II— characterised by Stiffness (frozen phase). Scapulothoracic symptoms predominate in this phase due to compensatory mechanisms.
Stage 1: Preadhesive; full motion with pain especially at night
Stage 2: Acute adhesive synovitis; mild restriction of movements and pain as predominant feature
Stage 3: Maturation: Motion significantly restricted with less severe pain
Stage 4: Chronic; severe painless restriction of movements
- Is mainly a clinical one.
- Impingement test helps to rule out rotator cuff disease.
- X-rays: disuse osteopenia, rules out other causes
- A saline-contrast MRI or traditional arthrogram will demonstrate decreased capsular volume with obliteration of the inferior capsular fold, and it will exclude abnormality of the rotator cuff
- Capsular and synovial thickness of >4 mm on MRI, adjacent to axillary recess is highly specific
- Other MRI findings include scarring in rotator cuff interval and joint capsule hypervascularity on gadolinium enhancement
- Physical therapy is the mainstay of treatment, regardless of stage
- Gentle progressive stretching is advocated and strengthening required rarely
- Initial nonoperative treatment analgesics, TENS, ultrasound, exercises. Abduction should be avoided initially to prevent impingement until joint motion becomes more supple
- Intraarticular or oral steroid may be useful in early phases especially with image guided injections but Longer-term follow-up shows no difference between patients treated with steroids and controls
- Patients who have more severe symptoms initially, are younger at the time of onset, and who experience a reduction in motion despite 4-6 months of compliant therapy are most likely to require surgery/manipulation
- Closed manipulation: Upto 94% patients have subjective relief which is sustained at long term follow-up
- Proper technique ensures rupture of inferior capsule from the humerus without causing rupture of the subscapularis or humeral fracture
- Technique: Flexion, Extension, Abduction, Adduction, external and internal Rotation (acronym: FEAR). Post manipulation, 20 ml of 0.5% bupivacaine and corticosteroid may be injected into the joint to reduce the inflammatory symptoms and pain
- Some surgeons advocate external rotation before elevation of arm to avoid humeral fracture or dislocation by clearing greater tuberosity from beneath the acromion
- Manipulation should be avoided in patients with osteopenia or recently healed fractures and reserved for patients with recalcitrant stiffness unresponsive to conservative management
- Arthroscopic capsular release has supplanted manipulation under anesthesia as it allows complete inspection of the joint, confirmation of the diagnosis, and a more precise capsulotomy without the risks
- Compared with manipulation, arthroscopic release has shown improvedpain relief and restoration of function which is maintained at long term follow-up
- Anterior release is always done with or without posterior release. Several studies have demonstrated early benefits of routine release of posterior capsule although outcome at longer follow-up are similar to isolated anterior release
- Others advocate posterior release for cases showing persistent loss of internal rotation after anterior release
- Arthroscopic release should be followed by early, diligent, and directed therapy to prevent recurrent stiffness
1. Andrew S. Neviaser, MD, Robert J. Neviaser, MD J Am Acad Orthop Surg 2011;19: