Adhesive Capsulitis (Frozen Shoulder)

Basics

Description

  • Frozen shoulder, or adhesive capsulitis (AC):
    • Characterized by progressive pain and stiffness of the shoulder
    • Usually resolves after 18 months
    • Global limitation of movement for active and passive movements
    • Unlike early disease (typically painful), late AC can present as pain-free restricted motion.
    • Associated with deltoid atrophy, decreased range of motion (ROM), especially for external rotation
  • Subtypes:
    • Primary adhesive capsulitis:
      • Idiopathic
      • Usually associated with diabetes mellitus (DM)
      • Typically resolves in 9 to 18 months (1)
    • Secondary adhesive capsulitis:
      • Typically due to prolonged immobilization
      • Sometimes called “shoulder-hand-syndrome” which is a complex regional pain syndrome (or reflex sympathetic dystrophy), if it is characterized by shoulder pain, diffuse swelling, and decreased ROM (1)
  • Clinical course:
    • Phase 1 (2 to 9 months): painful phase. Pain is constant. Diagnosis may be difficult if restricted movement is not present in early disease.
    • Phase 2 (4 to 12 months): Stiffening or freezing phase. Movement becomes restricted, and pain is no longer constant but present during end ranges of movement. Pain is also less severe.
    • Phase 3 (12 to 42 months): Resolution or thawing phase. End range pain can persist until complete resolution.

Epidemiology

  • Highest incidence in ages 50 to 60 years, women > men
  • Incidence: 2.4 per 1,000 population per year
  • Prevalence: 2–5% in the general population, 10–20% among diabetics (1)

Etiology and Pathophysiology

Underlying fundamental processes:

  • Inflammation: Mast cells, T cells, B cells, and macrophages have been identified histologically, suggesting an inflammatory process.
  • Angiogenesis
  • Scarring: Fibroblasts and myofibroblasts have been identified histologically. Capsular contracture reduces the joint volume to 3 to 4 mL compared to the normal 10 to 15 mL.

Genetics
No predisposition identified

Risk Factors

  • Shoulder immobilization; often due to impingement syndrome (most significant risk factor)
  • Age >49 years
  • Female gender
  • Diabetes
  • Cervical disc disease
  • Nondominant shoulder involvement
  • Hyperthyroidism
  • Atherosclerotic cardiovascular disease (ASCVD): cerebrovascular accident (CVA)/myocardial infarction (MI)
  • Autoimmune disease
  • Antiretroviral medication use
  • Parkinson disease
  • Trauma/surgery
  • Prior history of AC in contralateral shoulder

General Prevention

  • Active lifestyle, while avoiding shoulder injury
  • Control of diabetes, atherosclerotic disease, thyroid, and autoimmune conditions

Commonly Associated Conditions

DM, autoimmune disorders, Parkinson disease, highly active antiretroviral therapy (HAART) use, CVA/MI, cervical disc disease, hyperthyroidism

Diagnosis

History

  • Identify possible risk factors.
  • Progressive and worsening stiffness of the glenohumeral (GH) joint
  • Majority will have diffuse shoulder pain, especially at the beginning of the disease.
  • On the late phase of the disease, stiffness becomes predominant.

Physical Exam

  • Limitation in both active and passive ROM (especially passive external rotation of shoulder <30 degrees)
  • Pain to provocation of subacromial space
  • Inability to reach overhead or back pocket
  • Scapular substitution frequently accompanies active shoulder movement.
  • Injection test can be helpful in differentiating AC from subacromial pathologies such as rotator cuff tendinopathy (which improves with injection of local anesthetics, in contrast to AC). This should only be done if the diagnosis is still uncertain after a thorough history and physical.

Differential Diagnosis

  • Rotator cuff strain/tear/impingement syndrome
  • GH or acromioclavicular joint osteoarthritis (OA)
  • Cervical strain/radiculopathy/OA
  • Subacromial bursitis
  • Parsonage-Turner syndrome: brachial plexus inflammation secondary to a trigger, such as an infection, trauma, or autoimmune condition
  • Myofascial pain syndrome
  • Calcific tendonitis
  • Fracture, posterior dislocation
  • Bony neoplasm/metastasis

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)
  • No labs are required for idiopathic AC. Blood tests can be used to rule out secondary causes such as diabetes, thyroid disease, a stroke, autoimmune diseases, and, in rare cases, Parkinson disease (e.g., thyroid stimulating hormone, hemoglobin A1C, erythrocyte sedimentation rate).
  • Imaging:
    • Plain radiographs of the affected shoulder (postero-anterior, external rotation, axillary, and supraspinatus outlet views)
      • Preferred initial tests
      • In most cases, will be negative
      • Used primarily to rule out other pathologies such as GH OA, fractures, dislocation, or tumors (1)
    • In late AC, the plain radiographs can show diffuse osteopenia of the proximal humerus.
    • Magnetic resonance imaging (MRI)
      • Not indicated unless there is a concomitant pathology in the shoulder, or neurologic deficit
      • May show thickening of the joint capsule and the coracohumeral ligament, along with edema and increased joint fluid (1)
    • Ultrasound (US)
      • Indications similar to those for MRI
      • Selection depends on individual cases and clinician’s preference.
      • Can also reveal joint capsule thickening and increased joint fluid
      • Doppler can show increased vascularity around the intraarticular portion of the biceps tendon and coracohumeral ligament.

Treatment

  • In most cases, self-limited
  • Manage patient expectations; resolution often takes 18 months of medication and rehabilitation.

Medication

  • Pain management
    • Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are first line of treatment.
  • Glucocorticoid injections:
    • Can be beneficial especially when administered at the beginning of the disease
    • A short course of physical therapy after an injection, for 4 to 6 weeks, can improve pain and ROM (2).
    • Injection may be diluted with a local anesthetic like lidocaine. Triamcinolone 20 to 40 mg or methylprednisolone 20 to 40 mg can be used.
  • Oral glucocorticoids
    • Short course of oral glucocorticoids can reduce pain and improve mobility (2).
    • Usually given for approximately 3 weeks (prednisolone 30 mg/day × 3 weeks) but for no >6 weeks
    • Not to be given as routine treatment (significant side effects)

Additional Therapies

  • Exercise and physical therapy:
    • Gentle ROM exercises should be offered to every patient.
    • Exercises should be performed daily and as tolerated. A structured plan should be given to the patient (3).
    • Physical therapy has been found to be beneficial especially in phases 2 and 3 of AC. Best data supports its use in conjunction with other treatment, like corticosteroids (4).
  • Laser has been suggested as a possible treatment, particularly for pain relief; not enough evidence for support.

Surgery/Other Procedures

  • No evidence of benefit
  • Should be reserved for patients who do not respond to conservative measures for at least 1 year
  • Arthroscopy release is the most common technique used.

Ongoing Care

Follow-up Recommendations

  • After establishing a diagnosis, assess the need for pain control, and start the patient on NSAIDs, in combination with a gentle exercise program.
  • Follow up in 3 to 4 weeks: if no significant improvement, may consider intra-articular corticosteroid injections along with physical therapy (4)
  • Follow up in 2 to 3 months: Increase intensity of the exercises as the patient progresses. Physical therapy can also be prescribed at this point.
  • For secondary AC, consider evaluation by a multidisciplinary team.
  • Follow up in 10 to 12 months: If no improvement, consider surgical intervention.

Patient Education

  • Patient education is important; explain prognosis and ensure compliance with treatment.
  • Climbing the wall: Face a wall and place the hand from the affected shoulder flat on the surface of the wall; use the fingers to “climb” the wall; pause 30 seconds every few inches. Repeat the exercise after turning the torso 90 degrees to wall (abduction).
  • In case of secondary AC, address the importance of treating underlying causes.

Prognosis

Up to 50% will have permanent limitation, mostly with external rotation.

Codes

ICD-10

  • M75.00 Adhesive capsulitis of unspecified shoulder
  • M75.01 Adhesive capsulitis of right shoulder
  • M75.02 Adhesive capsulitis of left shoulder

ICD-9

  • 726.0 Adhesive capsulitis of shoulder

SNOMED

  • 15635961000119100 Bilateral adhesive capsulitis of shoulders (disorder)
  • 301971000119109 Adhesive capsulitis of right shoulder (disorder)
  • 301981000119107 Adhesive capsulitis of left shoulder (disorder)
  • 399114005 adhesive capsulitis of shoulder (disorder)
  • 430474001 Secondary adhesive capsulitis (disorder)

Clinical Pearls

  • Frozen shoulder or AC is generally a self-limiting global restriction in ROM of the shoulder joint. Up to 50% will have permanent inability to externally rotate the shoulder.
  • Natural course consists of a painful phase, freezing phase, and thawing phase. It occurs mostly in older women; total prevalence is 2–5% of the general population and roughly 10–20% of the diabetic population.
  • Most common physical exam finding is the inability to externally rotate the shoulder. Other signs include pain on provocation of subacromial space and inability to reach overhead or for back pocket.
  • Plain x-rays are the preferred initial imaging modality. MRI and US are done only if there is concomitant pathology or neurologic deficit.
  • Treatment includes pain control with NSAIDs, acetaminophen, or opiates; glucocorticoid therapy (injections or short course of oral steroids); physical therapy; or surgery.
  • Resolution of symptoms often takes 18 or more months.

Authors


Berenice Subero Pablo, MD
Mena Megellie, MD
George G.A. Pujalte, MD, FACSM

Bibliography

  1. Rangan A, Goodchild L, Gibson J, et al. Frozen shoulder. Shoulder Elbow. 2015;7(4):299–307.  [PMID:27582992]
  2. Page MJ, Green S, Kramer S, et al. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014;(8):CD011275. [PMID:25157702]
  3. Jain TK, Sharma NK. The effectiveness of physiotherapeutic interventions in treatment of frozen shoulder/adhesive capsulitis: a systematic review. J Back Musculoskelet Rehabil. 2014;27(3):247–273.  [PMID:24284277]
  4. Russel S, Jariwala A, Conlon R, et al. A blinded, randomized, controlled trial assessing conservative management strategies for frozen shoulder. J Shoulder Elbow Surg. 2014;23(4):500–507.  [PMID:24630545]


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