Adhesive Capsulitis(Frozen Shoulder)

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
1. Intrinsic: Shoulder fracture, tendonitis, rotator cuff tear, degenerative joint disease
2. 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.

Pathology:

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

Clinical Features

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.

Phase III—Thawing

Arthroscopic Staging

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

Diagnosis:

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

Treatment

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