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Adhesive Capsulitis (Frozen Shoulder)

  • Author: Albert W Pearsall, IV, MD; Chief Editor: S Ashfaq Hasan, MD  more...
 
Updated: Dec 28, 2015
 

Background

Adhesive capsulitis and frozen shoulder syndrome (FSS) are two terms that have been used to describe a painful and stiff shoulder. Historically, the criteria for diagnosing an individual with a frozen shoulder have varied; this has led to inclusion of conditions such as subacromial bursitiscalcifying tendinitis, and partial rotator cuff tears. However it is important to note that the current consensus definiton of a frozen shoulder by the American Shoulder and Elbow Surgeons is "a condition of uncertain etiology characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder."[1]

The loss of passive range of motion (ROM) is a critical element in establishing the diagnosis of a true frozen shoulder. Although conditions such as subacromial bursitis, calciifc tendinitis, and partial rotator cuff tears can be associated with significant pain and loss of active ROM, passive ROM is preserved. Therefore, patients with those conditions should not be classified as having a frozen shoulder.

Lundberg divided patients who met the pain and motion requirements of frozen shoulder into two groups: primary and secondary.[2] A patient meets the criteria of primary or secondary FSS if painful, restricted active and passive glenohumeral and scapulothoracic motion occurs for at least 1 month and has either reached a plateau or worsened. This inclusion period for defining frozen shoulder is similar to that described by Binder and colleagues[3, 4] but is shorter than that defined by Lloyd-Roberts and coworkers.[5]

Patients with primary frozen shoulder have no significant findings in the history, clinical examination, or radiographic evaluation to explain their motion loss and pain. Classically, symptoms of primary frozen shoulder have been divided into three phases: painful, stiffening, and thawing.

The initial painful phase is marked by a gradual onset of diffuse shoulder pain lasting from weeks to months. The stiffening phase is characterized by a progressive loss of ROM that may last up to 1 year. Most patients lose glenohumeral external rotation, internal rotation, and abduction during this phase. The final, thawing phase is measured in weeks to months and constitutes a period of gradual motion improvement. Once in this phase, the patient may require up to 9 months to regain a functional ROM.[6, 7, 8, 9]

In contrast to patients with primary FSS, patients with secondary FSS describe an event that preceded the onset of shoulder symptoms, such as trauma or surgery to the affected upper extremity.

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Problem

Codman originally coined the term frozen shoulder to describe a condition with the following signs and symptoms[10] :

  • Slow-onset shoulder pain
  • Localized discomfort near the deltoid insertion
  • Inability to sleep on the affected side
  • Restricted glenohumeral elevation and external rotation
  • A normal radiologic appearance

The inclusion criteria for FSS include painful restriction of active and passive glenohumeral and/or periscapular motion. Despite these criteria, diagnosing FSS can be controversial because there is little consensus on specific shoulder motion restrictions or duration of symptoms needed to qualify a patient as having a frozen shoulder. Although various authors have classified patients with FSS as those with limited abduction from 45-135º, FSS is still primarily a clinical diagnosis based on clinical motion loss and symptoms.

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Epidemiology

Frequency

Frozen shoulder syndrome usually affects patients aged 40-70 years. The incidence of FSS is not precisely known; however, it is estimated that 3% of people develop the disease over their lifetime. Males tend to be affected less frequently than females, and there is no predilection for race.

Adhesive capsulitis has been associated with several conditions. A higher incidence of frozen shoulder exists among patients with diabetes (10-20%) compared with the general population (2-5%). Incidence among patients with insulin-dependent diabetes is even higher (36%), with an increased frequency of bilateral shoulder involvement.[11]  In general, bilateral shoulder involvement is rarely simultaneous and instead occurs sequentially.

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Etiology

Duplay was one of the first physicians to present the concept of periarticular tissue pathology rather than periarticular arthritis as the cause of frozen shoulder.[12] Despite a lack of evidence linking frozen shoulder to a specific etiology, various triggers that may predispose patients to this problem appear to exist. A few reported etiologic agents include the following:

  • Trauma
  • Surgery (including but not limited to shoulder surgery)
  • Inflammatory disease
  • Diabetes
  • Regional conditions
  • Various shoulder maladies

In addition, an autoimmune theory has been postulated, with elevated levels of C-reactive protein and an increased incidence of HLA-B27 histocompatibility antigen reported in patients with frozen shoulder versus controls.[13, 14] DePalma proposed that muscular inactivity was a major etiologic factor,[15] while Bridgman identified an increased incidence of FSS in patients with diabetes mellitus.[16] Finally, frozen shoulder also has been associated with cervical spine disease, Parkinson disease,[17] hyperthyroidism,[18] and ischemic heart disease.

Most patients with FSS have a period of shoulder immobilization. Reasons for immobilization can be diverse; however, the common finding in all of these patients is a period of restricted shoulder motion. In a study of neurosurgery patients who immobilized their shoulders for varying periods, Bruckner noted an incidence of frozen shoulder that was 5-9 times greater than that found in the general population.[19]

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Presentation

Prior to examining the patient, a thorough clinical history should be elicited. Specifically, information should be gathered regarding the following:

  • Onset of symptoms
  • Any antecedent trauma or surgery
  • Affected side(s)
  • Duration of symptoms

The patient should also be queried about any existing medical conditions. Given the strong association of adhesive capsulitis with diabetes, it is imperative to screen any new patient presenting with possible frozen shoulder syndrome for diabetes or prediabetes. Adhesive capsulitis has also been reported in patients with hyperthyroidism, and ischemic heart disease. Questions should be directed toward any upper extremity neurologic complaints, including cervical radiculopathy. Any history of cervical pain or radiculopathy should be thoroughly evaluated during the clinical examination to exclude a diagnosis of cervical spondylosisor cervical disc disease.

Any previous treatments that the patient has received for their condition should be documented, as should the individual's current medication list.

The patient's posture should be observed while he or she is wearing a gown and sitting on a stool. The examiner should note whether the patient is listing to one side secondary to pain, or holding the neck to one side secondary to spasm or pain. Such initial observations help determine whether a cervical condition may be contributing to the patient's symptomatology.

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Indications

Refractory shoulder periscapular pain and limited glenohumeral motion that persists despite a period of at least 3 months of attempted conservative treatment are indications for surgery. Conservative treatment can include the following:

  • A course of prednisone [20]
  • A course of nonsteroidal anti-inflammatory medicine when not on prednisone
  • A subacromial or glenohumeral intra-articular injection at least once but not more than twice within a 3-month period
  • Physical therapy for ROM of the shoulder [21, 22, 23]
  • A physician-directed home therapy program has been shown to have efficacy in helping restore range of motion [67]  
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Relevant Anatomy

Critical to the understanding of frozen shoulder syndrome is the concept that shoulder function involves not only the glenohumeral joint but also scapulothoracic articulation. Clinicians must understand the essential role that the scapula plays in facilitating glenohumeral motion. Scapulothoracic and glenohumeral motion occur simultaneously following initial arm abduction. With arm abduction in individuals who are healthy, approximately one third of elevation is attributed to scapulothoracic motion, while two thirds of elevation is provided by glenohumeral motion.

The glenohumeral joint is enclosed by the joint capsule and is surrounded by two sleeves of muscles. The capsule normally is a loose structure with a surface area nearly twice as large as that of the humeral head. The rotator cuff tendons adjacent to the joint capsule thicken the capsule anteriorly, posteriorly, and superiorly, while the glenohumeral ligaments represent further areas of joint capsule thickening.

Histologically, the capsule consists of bundles of type I collagen. Synovial cells line the inner surface of the capsule and enclose the long head of the biceps tendon.

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Contraindications

Contraindications to surgical intervention for recalcitrant frozen shoulder include the following:

  • Concomitant neurologic complaints or abnormalities originating from the cervical spine
  • An inadequate trial of conservative therapy (<3 mo)
  • Ongoing infection of any type [24]
  • Isolated capsular release in the face of adhesive capsulitis and concomitant glenohumeral arthritis (in this situation, capsular release or lengthening should be performed in conjunction with total shoulder arthroplasty)
  • Ongoing oncologic process involving the affected shoulder
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Contributor Information and Disclosures
Author

Albert W Pearsall, IV, MD Associate Professor, Department of Orthopedic Surgery, University of South Alabama College of Medicine; Director, Section of Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, University of South Alabama Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

S Ashfaq Hasan, MD Associate Professor, Chief, Shoulder and Elbow Service, Department of Orthopaedics, University of Maryland School of Medicine

S Ashfaq Hasan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Shoulder and Elbow Surgeons

Disclosure: Nothing to disclose.

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True anteroposterior view of the glenohumeral joint (left); axillary lateral view (middle); supraspinatus outlet view (right)
Table 1.
Corticosteroid Dosing in Patients With Refractive Frozen Shoulder Syndrome*
Week Number Medication Dose
1 (Days 1-7) Prednisone 40 mg/d
2 (Days 8-14) Prednisone 30 mg/d
3 (Days 15-18) Prednisone 20 mg/d
4 (Days 19-21) Prednisone 10 mg/d
5 (Days 22+) Discontinue ----
*Before oral corticosteroid medication is prescribed, the patient should be extensively questioned about pertinent medical problems that may be contraindications to taking the medicine.
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