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Updated: Feb 29 2024

Adhesive Capsulitis (Frozen Shoulder)

Images capsulitis.jpg interval cadaver dissection.jpg release.jpg
  • Summary
    • Adhesive capsulitis (also known as frozen shoulder) is a condition of the shoulder characterized by functional loss of both passive and active shoulder motion commonly associated with diabetes, and thyroid disease.
    • Diagnosis is made clinically with marked reduction of both active and passive range of motion of the shoulder.
    • Treatment is a prolonged course of aggressive physical therapy and medical management of underlying disease if present (i.e diabetes, thyroid disorder). Manipulation under anesthesia or arthroscopic capsular release is indicated in patients with progressive loss of motion having failed a prolonged course of physical therapy. 
  • Epidemiology
    • Demographics
      • more common among women
      • ages 40-60 years
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • primary, idiopathic form
        • post-traumatic (following proximal humerus fracture or immobilization for other upper extremity injury)
        • post-surgical (following rotator cuff repair or axillary dissection for malignancy)
      • pathoanatomy
        • inflammatory process causing fibroblastic proliferation of joint capsule leading to thickening, fibrosis, and adherence of the capsule to itself and humerus
        • fibroblasts/myofibroblasts with abundant Type III collagen present
        • leads to mechanical block to motion
        • essential lesion involves the coracohumeral ligament and rotator interval capsule
    • Associated conditions
      • diabetes (both types)
        • stiffness may be first manifestation of diabetes and warrants further workup
        • worse outcomes regardless of treatment
        • increased risk with older age, increased duration of DM, autonomic neuropathy, history of MI
      • thyroid disorders (autoimmune etiology)
      • dupuytren's disease
      • atherosclerotic disease
      • cervical disc disease
  • Anatomy
    • Capsuloligamentous structures
      • function
        • contribute to stability of the glenohumeral joint
        • act as check reins at extremes of motion in their non-pathologic state
      • glenohumeral ligaments
        • superior glenohumeral ligament (SGHL)
        • middle glenohumeral ligament (MGHL)
        • inferior glenohumeral ligament (IGHL) complex with the following components
          • anterior band
          • axillary fold
          • posterior band
    • Rotator interval
      • a triangular region between the anterior border of supraspinatus and the superior border of subscapularis
      • contains the SGHL and coracohumeral ligament
  • Classification
      • Clinical Stages
      • Freezing/Painful
      • Gradual onset of diffuse pain (6 wks to 9 months)
      • Frozen/Stiff
      • Decreased ROM affecting activities of daily living (4 to 9 months or more)
      • Thawing
      • Gradual return of motion (5 to 26 months)
      • Arthroscopic Stages
      • Stage 1
      • Patchy, fibrinous synovitis
      • Stage 2
      • Capsular contraction and fibrinous adhesions
      • Stage 3
      • Increasing contraction, synovitis resolving
      • Stage 4
      • Severe contraction
  • Presentation
    • Symptoms
      • common symptoms
        • often insidious onset of general shoulder pain preceding any noticeable loss of motion
        • variable character and severity of pain, loss of motion dependent on the stage of disease at presentation
        • freezing- insidious onset of pain at rest and with movement, difficulty sleeping
        • frozen- pain lessens but significant motion limitations affecting ADLs
        • thawing- pain is gone and motion improves but less than normal
    • Physical exam
      • inspection
        • note any muscle atrophy or scars denoting prior surgery
      • motion
        • symmetric loss of active and passive ROM
        • document all motion planes and compare to contralateral side
        • limitations in motion may be slight, external rotation deficit most common finding
        • tethered endpoint to motion
        • pain throughout motion arc or at terminal motion depending on stage of disease
      • provocative tests
        • impingement, biceps, and SLAP maneuvers often positive
        • rotator cuff testing may be limited given loss of motion
  • Studies
    • Metabolic panel and endocrine labs (TSH, A1c)
  • Imaging
    • Radiographs
      • recommended views
        • AP in neutral rotation
        • scapular-Y
        • axillary lateral
      • alternate views
        • AP in internal and external rotation
      • findings
        • disuse osteopenia
        • must be obtained to evaluate for osteoarthritis, posterior dislocation, or surgical hardware
    • MRI +/- arthrography
      • indications
        • not necessary for diagnosis but can evaluate for other pathology
      • findings
        • loss of axillary recess indicates contracture of joint capsule
  • Treatment
    • Nonoperative
      • physical therapy, NSAIDs and/or intra-articular steroid injections, heat and/or cryotherapy
        • indications
          • first-line treatment, often effective
          • physical therapy program of gentle, pain-free stretching and moist heat
          • should be supervised and last for 3-6 months
      • distension arthrography
        • rarely performed
    • Operative
      • manipulation under anesthesia (MUA)
        • indications
          • failure to improve with non-operative modalities
        • contraindications
          • controversial if done during freezing/inflammatory phase
          • diabetics- 50% failure rate
          • following rotator cuff or labral repair
      • arthroscopic or open capsular release
        • indications
          • after extensive therapy has failed (3 months)
          • arthroscopy will spare subscapularis tendon with the advantage of releasing intra-articular and subacromial adhesions
  • Techniques
    • Physical therapy
      • daily progressive stretching exercises to point of pain
      • supervised or home-based programs
      • successful for overwhelming majority
    • Manipulation under anesthesia
      • assess and document pre-procedure range of motion
      • anesthesia
        • complete muscle paralysis required
        • in-dwelling catheter for regional anesthesia often used to aid in therapy
      • manipulation
        • steady force applied after full muscle paralysis achieved
      • postoperative
        • early physical therapy program initiated
      • complications
        • fracture, dislocation, rotator cuff and labral tears
        • brachial plexus palsies
    • Arthroscopic capsular release
      • assess and document pre-procedure range of motion
      • anesthesia
        • in-dwelling catheter for regional anesthesia often used to aid in therapy
      • approach
        • standard skin incisions with portal placement slightly higher than normal given contracted and thickened capsule
      • release
        • intra-articular structures may be obscured by adhesions and contractures
        • rotator interval released from anterior biceps tendon to superior edge of subscapularis
        • coracohumeral ligament can then be visualized and released
        • posterior capsular release will increase IR and cross-body adduction
        • subacromial bursectomy and adhesions released as needed, no acromioplasty done
      • manipulation
        • MUA may be done before or after release to increase to range of motion
      • postoperative
        • early physical therapy program initiated
  • Complications
    • Axillary nerve injury with capsular release
      • perform inferior release near to glenoid rim
    • Proximal humerus fracture, dislocation, rotator cuff tears or brachial plexopathy
      • following overzealous manipulation with osteoporotic bone
  • Prognosis
    • Self-limited disease
    • Worse outcomes among diabetics
    • After surgical treatment, gains in range of motion and improved function are maintained at long-term follow
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