You are in: eMedicine Specialties > Orthopedic Surgery > SHOULDER Adhesive CapsulitisArticle Last Updated: Aug 12, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Albert W Pearsall IV, MD, Associate Professor, Department of Orthopedic Surgery, University of South Alabama; Director, Section of Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, University of South Alabama Medical Center Editors: Lynn A Crosby, MD, FACS, Chief of Shoulder Division, Professor, Department of Orthopedic Surgery, Wright State University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Pekka A Mooar, MD, Associate Professor, Department of Orthopedic Surgery, Temple University School of Medicine; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; 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 Author and Editor Disclosure Synonyms and related keywords: adhesive capsulitis, frozen shoulder, frozen shoulder syndrome, FSS, bursitis, joint disease, capsulitis shoulder, adhesive shoulder, adhesive joint, frozen shoulder treatment, shoulder pain, stiff shoulder INTRODUCTIONSection 2 of 12
  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 colleagues2, 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. ProblemCodman 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 45-135º, it is still primarily a clinical diagnosis based on clinical motion loss and symptoms. FrequencyFrozen 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 EtiologyDuplay 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:
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 ClinicalPrior 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. INDICATIONSSection 3 of 12
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:
RELEVANT ANATOMYSection 4 of 12
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. CONTRAINDICATIONSSection 5 of 12
Contraindications to surgical intervention for recalcitrant frozen shoulder include the following:
WORKUPSection 6 of 12
Lab Studies
Imaging Studies
Histologic FindingsMany patients with adhesive capsulitis demonstrate arthroscopic evidence of proliferative synovitis, capsular and intra-articular subscapularis tendon thickening, and fibrosis and chronic inflammatory cells. The majority of significant synovitis is noted, although it is not limited to the anterior capsule. In addition, most patients demonstrate significant subacromial fibrosis. In one study, the author noted that approximately 40% of patients had significant subacromial fibrosis, regardless of preoperative etiology. TREATMENTSection 7 of 12
Medical TherapyIdiopathic adhesive capsulitis affecting the glenohumeral joint is believed to be self-limiting and is often treated effectively with physical therapy and medications. However, studies on the natural history of the condition have noted long-term pain in many patients following nonoperative treatment, with as many as 10% of patients never fully recovering normal shoulder activities. Various authors have reported an inflammatory component to frozen shoulder syndrome. Therefore, the use of nonsteroidal medications in the initial treatment phase of frozen shoulder is recommended. By diminishing inflammation and pain, the patient is better able to tolerate aggressive physical therapy. Before the patient is prescribed any medication, he or she should be queried about any contraindications to nonsteroidal medicines. Depending on the severity of symptoms, a 3-week tapered course of oral corticosteroids should be prescribed in lieu of nonsteroidal medication (see Table 1). Due to potential side effects of this medicine, the patient should be thoroughly questioned regarding past medical history, including diabetes mellitus. Diabetes mellitus is not an absolute contraindication to the use of oral corticosteroids; however, because of the potential hyperglycemic effects of corticosteroids, it should be used judiciously and the patient's blood glucose should be closely monitored. The use of low-dose oral corticosteroids is recommended only in cases of severe refractory frozen shoulder that has either been present for an extended period (ie, longer than 2 mo) or is causing significant pain.19, 10, 20 Oral corticosteroids provide an even stronger anti-inflammatory effect than do nonsteroidal medications. Either type of medication may be used in conjunction with a subacromial corticosteroid injection. Because adhesive capsulitis is rare in children, any of the previously mentioned medications rarely are used in this population. Most pediatric patients respond to conservative physical therapy without the use of medications.
*Before oral corticosteroid medication is prescribed, the patient should be extensively questioned about pertinent medical problems that may be contraindications to taking the medicine. Surgical TherapyA subgroup of patients with frozen shoulder syndrome often fail to improve despite treatment with aggressive nonsurgical therapy and medication. These patients frequently are referred to as having a refractory or recalcitrant frozen shoulder. Specifically, these patients demonstrate minimal improvement in shoulder pain and motion over a 3-month period, despite the use of aggressive nonoperative measures, including medications and physical therapy. In these refractory cases, more invasive techniques (eg, manipulation, distention arthrography, open surgical release) may be needed. Although several authors have championed the success of these therapies, significant complications, ranging from biceps tendon sheath and subscapularis tendon rupture to humeral fracture, have been reported with various nonsurgical treatments. Ogilvie-Harris and Warner have demonstrated the efficacy of arthroscopic capsular release for the refractory frozen shoulder.21, 22, 23 Based on these reports and work by others, a selective arthroscopic capsular release is recommended for patients with refractory frozen shoulder. Following a thorough preoperative assessment of the affected and unaffected shoulder's passive range of motion (PROM), standard arthroscopic shoulder portals are established. Based on the preoperative examination, the anterior and/or posterior glenohumeral joint capsule is released with electrocautery (see Image 1). Before the patient is taken from the operating room, the individual's ROM is documented and compared with his or her presurgical motion. With 24-48 hours of postoperative pain relief provided by a preoperative interscalene block, ROM exercises should be initiated on the day of surgery. A 2-week course of oral corticosteroids also should be initiated on the day of surgery. Postoperative DetailsFurther inpatient care is indicated only in refractory patients. Patients receiving arthroscopic or open capsular release frequently are in the hospital for several days to permit interscalene anesthesia and aggressive, monitored physical therapy. However, patients rarely have to return to the hospital following the initial surgery. A small group of patients with adhesive capsulitis relapse, despite surgical intervention and physical therapy; admitting these patients for interscalene anesthesia and aggressive physical therapy may be appropriate. Most patients with adhesive capsulitis use either an anti-inflammatory medication or a short course of an oral corticosteroid. Occasionally, patients may require medication for pain. A chronic-pain medication such as Neurontin or Elavil is preferred for these symptoms. Follow-upPatients with adhesive capsulitis—those who have been treated with conservative therapy and those who have had surgical intervention—should be closely monitored as outpatients. Usually, supervised or home physical therapy is a component of treatment. In addition, the patient may be taking oral corticosteroids, which must be monitored for side effects. The patient should be monitored every several weeks to document progress. The patient should be monitored at 2-week intervals for the first month after surgery. Thereafter, follow-up intervals can be increased from 6 weeks to 3 months, as needed. COMPLICATIONSSection 8 of 12
The predominant complication arising from adhesive capsulitis is residual shoulder stiffness or pain. Several reports have indicated that most patients may continue to have pain and/or stiffness for up to 3 years following conservative treatment. In addition, humeral fracture, biceps tendon rupture, and subscapularis tendon rupture have been reported after shoulder manipulation. OUTCOME AND PROGNOSISSection 9 of 12
In the past, frozen shoulder was considered a self-limiting condition that could be treated with physical therapy and would resolve in 1-3 years. However, several studies have demonstrated long-term pain and shoulder stiffness following conservative treatment. Several studies have noted improved symptoms following arthroscopic capsular release. Warner and colleagues reported an improvement in the Constant and Murley score of 48 points with a mean follow-up of 39 months.24 Pearsall and colleagues found that 83% of patients reported their shoulder to be normal or near normal at an average of 22 months following capsular release.25 Ogilvie-Harris noted that 15 of 18 patients treated with arthroscopic capsular release had an excellent result at 2-5 years following surgery. A review of the literature indicates that in patients with refractory adhesive capsulitis, a near-excellent to excellent result of 75-90% can be expected with arthroscopic capsular release and an aggressive postoperative physical therapy regimen. FUTURE AND CONTROVERSIESSection 10 of 12
Hyperthyroidism, ischemic heart disease, diabetes mellitus,10 and cervical spondylosis have been associated with the occurrence of adhesive capsulitis. Patients with these conditions should be alerted to the increased risk of developing frozen shoulder. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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