Adhesive capsulitis of the shoulder

Adhesive capsulitis, also known as frozen shoulder, is a condition associated with

Symptoms include shoulder pain and limited range of motion although these symptoms are common in many shoulder conditions. An important symptom of adhesive capsulitis is the severity of stiffness that often makes it nearly impossible to carry out simple arm movements. Pain due to frozen shoulder is usually dull or aching and may be worse at night and with any motion.[7]

The symptoms of primary frozen shoulder have been described as having three^[8] or four stages.^[9] Sometimes a prodromal stage is described that can be present up to three months prior to the shoulder freezing. During this stage people describe sharp pain at end ranges of motion, achy pain at rest, and sleep disturbances.

• Stage one: The "freezing" or painful stage, which may last from six weeks to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.
• Stage two: The "frozen" or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage generally lasts from four to twelve^[10] months.
• Stage three: The "thawing" or recovery, when shoulder motion slowly returns toward normal. This generally lasts from 5 to 26 months.^[11]

Physical exam findings include restricted range of motion in all planes of movement in both active and passive

Primary adhesive capsulitis, also known as idiopathic adhesive capsulitis, occurs with no known trigger. It is more likely to develop in the non-dominant arm.^[citation needed]

Secondary

Adhesive capsulitis is called secondary when it develops after an injury or surgery to the shoulder.^{[citation needed]}

Pathophysiology

The underlying pathophysiology is incompletely understood, but is generally accepted to have both inflammatory and

The main limiting factor in external rotation is due to the thickening of the coracohumeral ligament, which forms the roof of the rotator cuff and is a primary symptom of adhesive capsulitis. In addition, the coracohumeral ligament attributes to the limitation of internal rotation considering its connection to the supraspinatus and subscapular tendons. As the phases of adhesive capsulitis progress, the glenohumeral capsule begins to thicken and as a result the contraction of the capsule itself becomes the main reason as to why range of motion will be restricted in all planes of motion.[14]

Diagnosis

Adhesive capsulitis can be diagnosed by history and physical exam. It is often a diagnosis of exclusion, as other causes of shoulder pain and stiffness must first be ruled out. On physical exam, 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.^{[citation needed]}

Imaging studies are not required for diagnosis, but may be used to rule out other causes of pain. Radiographs will often be normal, but imaging features of adhesive capsulitis can be seen on ultrasound or non-contrast

Grey-scale ultrasound can play a key role in timely diagnosis of adhesive capsulitis due to its high sensitivity and specificity. It is also widely available, convenient, and cost efficient. Thickening in the coracohumeral ligament, inferior capsule/ axillary recess capsule, and rotator interval abnormality, as well as restriction in range of motion in the shoulder can be detected using ultrasound. The range of motion is prohibited due to scapulohumeral rhythm changes occurring in the shoulder joint. The altered scapular kinematics can restrict anterior and posterior tilting, downward rotation and depression as well as external rotation. All of these restrictions lead the scapula to be excessively upwardly rotated. The restriction of the scapular posterior tilt is due to tightness in the lower serratus anterior, anterior capsule and the pectoralis minor. Downward rotation and depression are restricted due to the tightness of the rhomboids, upper trapezius and the superior capsule.^[17] Respective sensitivity values were 64.4, 82.1, 82.6, and 94.3, and respective specificity levels were 88.9, 95.7, 93.9, and 90.9.^[18]

Treatment

There is consensus that non-surgical management is the initial treatment of choice for frozen shoulder.^[19] There is no strong evidence to favor any particular approach; in fact, some reviews suggest that multi-modal approaches combining several treatments are better.^[20] The effects of most treatments are primarily short-term, focusing on alleviating symptoms such as shoulder pain and reduced joint movement. Common treatments include exercise, physical therapy, oral analgesics such as paracetamol and NSAIDs, and intra-articular corticosteroid injections. Non-surgical treatment may continue for months, with more complex treatments such as ESWT, movement under analgesia, and hydrodilatation. It is unclear if these treatments lead to a quicker resolution of the disorder, or only manage chronic symptoms. The condition generally resolves itself with or without treatment. If conservative measures have no effect and the condition is long-lasting, or if evidence suggests surgical intervention, there are also several surgical procedures that may alleviate the disorder.^[19]

Medication

Medications such as NSAIDs can be used for pain control. Oral steroids may provide short-term benefits in range of movement and pain but have side effects such as hyperglycemia. Corticosteroids may also be used by local injection. In the short and medium term, intra-articular corticosteroid injections appear most effective in pain alleviation and increase in range of motion, although the injection does carry complications.^[21] Unfortunately, the effects of medication are not long-lasting. Oral corticosteroids in particular should not be used consistently to treat adhesive capsulitis, because of the dangers associated with long-term use and the lack of long-term benefit.^{[citation needed]}

Exercise and physical therapy

Shoulder stretching and strengthening exercises improve shoulder function and decrease pain. When using intra-articular corticosteroid injections, the effects of exercise on short-term relief were not significant, although individual studies found some benefits.

Hydrodilatation or distension arthrography is controversial. However, some studies show that arthrographic distension may play a positive role in reducing pain and improve range of movement and function.^[23]

Manipulation of the shoulder under general anesthesia to break up the adhesions is sometimes used.

Surgery

If conservative measures are unsuccessful, surgery can be trialed. Surgery to cut the adhesions (capsular release) may be indicated in prolonged and severe cases; the procedure is usually performed by arthroscopy. Surgical evaluation of other problems with the shoulder, e.g., subacromial bursitis or rotator cuff tear, may be needed. Resistant adhesive capsulitis may respond to open release surgery. This technique allows the surgeon to find and correct the underlying cause of restricted shoulder movement such as contracture of coracohumeral ligament and rotator interval.

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.^[13]

Epidemiology

Adhesive capsulitis newly affects approximately 0.75% to 5.0% percent of people a year.

• Calcific tendinitis
• Milwaukee shoulder syndrome
• Shoulder injury related to vaccine administration

References