Review Question - QID 219967

This 51-year-old has a clinical presentation suggestive of adhesive capsulitis. Patients who are younger than 50 years of age, as well as diabetics, are at higher risk for bilateral disease (Answer 3).

Adhesive capsulitis is a common condition characterized by fibroblastic proliferation, which results in capsular contracture and ligamentous thickening. The condition is most commonly seen in middle-aged patients between 40-60 years of age, with a predilection for minorities and those with endocrine disorders, namely diabetes and thyroid disease. The first deficiency on physical exam is classically limited external rotation, which will be in both active and passive range of motion. While largely a clinical diagnosis, MRI can be obtained, demonstrating a contracted joint capsule and loss of the axillary recess, while thickening of the coracohumeral ligament (CHL) has also been described. The condition responds favorably to nonoperative treatment, which includes corticosteroid injections and physical therapy. Patients under the age of 50, as well as those with diabetes, have been found to experience bilateral disease, not simultaneously, but rather sequentially.

Li et al. prospectively examined the CHL integrity in 72 adhesive capsulitis patients undergoing shoulder MRI, which were then compared to 120 normal shoulder MRIs. The authors noted that visualization of the CHL was more difficult in those with adhesive capsulitis (8.3 vs 20.8%). At the same time, the CHL ligament was significantly thicker in those with adhesive capsulitis (3.99 ±1.68 mm) compared to those without (3.08±1.32 mm). The authors conclude that finding a thickened CHL on MRI can be indicative of adhesive capsulitis.

Kingston et al. performed a single-institution, retrospective analysis on 2,190 adhesive capsulitis patients to better delineate the epidemiology and risk factors for surgery. The authors found those with adhesive capsulitis to be younger (< 50 years), more likely to be Hispanic (OR: 4.85) or African American (OR: 1.71), and have diabetes (OR: 1.12). Older patients, racial minorities, and government-insured or uninsured patients were less likely to undergo surgery, while workers' compensation patients were 8 times likelier to receive surgery compared with privately insured patients (all with p < 0.01).

Lamplot et al. performed a prospective cohort study of 75 patients exhibiting adhesive capsulitis and undergoing conservative treatment (corticosteroid injections + four weeks of physical therapy) to identify risk factors for the development of contralateral disease. Two patients (3.3%) failed nonoperative treatment and underwent arthroscopic capsular release with good results. Twenty-two patients (36.7%) developed adhesive capsulitis in the contralateral shoulder, with a predilection for patients with diabetes and in patients younger than 50 years of age. The authors conclude nonoperative treatment is associated with high rates of success. However, diabetics who are under 50 years of age are at highest risk for the development of contralateral disease.

Figure A is a T2-weighted non-contrast MRI of the left shoulder demonstrating loss of the axillary recess, indicative of adhesive capsulitis.

Incorrect Answers:
Answer 1: The coracohumeral ligament is not visualized as well in those with adhesive capsulitis
Answer 2: While diabetes is a risk factor for adhesive capsulitis, minorities are at higher risk for the disease compared to Caucasians
Answer 4: Nonoperative management (corticosteroid injections, physical therapy) typically results in high rates of resolution
Answer 5: External rotation is typically the first restriction seen with range of motion