Adhesive Capsulitis 

  • Author: Albert W Pearsall IV, MD; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: Dec 2, 2011
 

Background

Adhesive capsulitis and frozen shoulder syndrome (FSS) are 2 terms that have been used to describe an array of clinical conditions, including subacromial bursitis, calcifying tendinitis, and partial rotator cuff tears. Despite the diverse nomenclature used to describe FSS, all of these terms denote different clinical conditions that may cause the painful restriction of active and passive glenohumeral and periscapular shoulder motion.

Lundberg divided patients who met the pain and motion requirements of frozen shoulder into 2 groups: primary and secondary.[1] 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 duration and has either reached a plateau or worsened. This inclusion period for defining frozen shoulder is similar to that described by Binder and colleagues[2, 3] but is shorter than that defined by Lloyd-Roberts and coworkers.[4]

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 3 phases: (1) the painful phase, (2) the stiffening phase, and (3) the thawing phase. In the initial painful phase, there is a gradual onset of diffuse shoulder pain lasting from weeks to months. The stiffening phase is characterized by a progressive loss of motion 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 range of motion (ROM).[5, 6, 7, 8]

In contrast to patients with primary FSS, patients with secondary FSS describe an event that preceded shoulder symptomatology, 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 signs and symptoms that include slow-onset shoulder pain, localized discomfort near the deltoid insertion, an inability to sleep on the affected side, restricted glenohumeral elevation and external rotation, and a normal radiologic appearance.[9] 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 45-135 º, it 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. 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.[10]

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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.[11] 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. DePalma proposed that muscular inactivity was a major etiologic factor,[12] while Bridgman identified an increased incidence of FSS in patients with diabetes mellitus.[13] Finally, frozen shoulder also has been associated with cervical disease, hyperthyroidism, 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.[14]

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Presentation

Prior to examining the patient, a thorough clinical history should be elicited. Specifically, information should be gathered regarding onset of symptoms, any antecedent trauma or surgery, affected side(s), and duration of symptoms. The patient should be queried about any existing conditions. Since adhesive capsulitis is associated with diabetes, it is imperative to screen any new patient presenting with suggested frozen shoulder syndrome for diabetes. Adhesive capsulitis has also been reported in patients with hyperthyroidism, ischemic heart disease, and cervical spondylosis. Any previous treatments that the patient has received for this condition should be documented, as should the individual's current medication list. 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.

The patient's posture should be observed while he or she is wearing a gown and sitting on a stool. It should also be noted whether the patient is listing to one side secondary to pain and whether he or she is holding the neck to one side secondary to spasm or pain. Observations during this period 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. The conservative treatment should include the following:

  • Physical therapy for ROM of the shoulder[15, 16]
  • A course of prednisone[17]
  • A subacromial injection at least once but not more than twice within a 3-month period
  • A course of anti-inflammatory medication when the patient is not taking prednisone
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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 2 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[18]
  • 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

Lynn A Crosby, MD, FACS  Chief of Shoulder Division, Professor, Department of Orthopedic Surgery, Wright State University School of Medicine

Lynn A Crosby, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American College of Surgeons, American Fracture Association, American Medical Association, American Medical Tennis Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Arthroscopy Association of North America, Mid-America Orthopaedic Association, and Orthopaedic Research Society

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD  Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

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 NumberMedicationDose
1 (Days 1-7)Prednisone40 mg/d
2 (Days 8-14)Prednisone30 mg/d
3 (Days 15-18)Prednisone20 mg/d
4 (Days 19-21)Prednisone10 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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