Updated: 3/24/2019

Adhesive Capsulitis (Frozen Shoulder)

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https://upload.orthobullets.com/topic/3059/images/adhesive capsulitis.jpg
https://upload.orthobullets.com/topic/3059/images/rotator interval.jpg
https://upload.orthobullets.com/topic/3059/images/rotator interval layers.jpg
https://upload.orthobullets.com/topic/3059/images/rotator interval cadaver dissection.jpg
https://upload.orthobullets.com/topic/3059/images/anterior release.jpg
Introduction
  • Overview
    • functional loss of passive and active shoulder motion with no underlying cause
  • Epidemiology
    • demographics
      • more common among women
      • ages 40-60 years
  • 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
  • Prognosis
    • self-limited disease
    • worse outcomes among diabetics
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 mos)
Frozen/Stiff Decreased ROM affecting activities of daily living (4 to 9 mos or more)
Thawing Gradual return of motion (5 to 26 mos)
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 signficant 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
  • Residual stiffness  
  • 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
 

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(OBQ12.71) Which of the following patients is most likely to have a fibroblastic proliferative process as a cause for their shoulder complaints? Review Topic

QID: 4431
1

65-year-old man with giant cell arteritis and bilateral shoulder pain and stiffness.

8%

(335/4361)

2

40-year-old man with a history of podagra who now has acute shoulder pain.

2%

(96/4361)

3

50-year-old woman with hypothyroidism and loss of both active and passive shoulder motion.

77%

(3341/4361)

4

65-year-old woman with ulnar drift of the fingers and shoulder pain and stiffness.

5%

(225/4361)

5

40-year-old woman with antinuclear antibodies with knee and shoulder pain

7%

(319/4361)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(SBQ11UE.31) A 45-year-old patient with a history of diabetes presents with increasing shoulder stiffness over the course of the past several months. She has tried non-steroidal anti-inflammatory drugs, but they have not alleviated her pain. On examination she has global pain with passive range of motion, forward elevation of 100 degrees, external rotation to neutral, and internal rotation to her iliac crest. Radiographs of the shoulder are normal. An MR arthrogram is most likely to show which of the following? Review Topic

QID: 4266
1

Massive retracted rotator cuff tear

3%

(125/4954)

2

Proliferative synovial process with hypertrophied synovium and extensive papillary projections

11%

(558/4954)

3

Decreased intra-capsular volume

84%

(4165/4954)

4

Subscapularis tear with long head of the biceps subluxation

1%

(60/4954)

5

Fluid extravasation down the humerus

0%

(23/4954)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ05.5) Which of the following is a known risk factor for the development of adhesive capsulitis of the shoulder? Review Topic

QID: 42
1

Menopause

1%

(9/1417)

2

Steroid use

0%

(6/1417)

3

Diabetes mellitus

64%

(911/1417)

4

Renal disease

1%

(9/1417)

5

All of the above

34%

(481/1417)

ML 3

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PREFERRED RESPONSE 3

(SBQ05UE.87) Which of the following is the most common outcome following non-operative management of adhesive capsulitis with a stretching program? Review Topic

QID: 1872
1

Functionally limiting pain

6%

(33/510)

2

Decreased range of motion compared to contralateral shoulder

82%

(420/510)

3

Recurrence of adhesive capsulitis

10%

(51/510)

4

Need for operative intervention

1%

(5/510)

5

Development of rotator cuff arthropathy

0%

(0/510)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ10.68) A 42-year-old female presents to your office with pain in the shoulder that has been present for 1 month, and she notes the shoulder is also becoming stiff. She has not previously sought treatment. After a full evaluation, you determine she has adhesive capsulitis, and is in the early stiffening stage. What treatment do you recommend? Review Topic

QID: 3158
1

Immediate aggressive therapy for active-assisted and passive range of motion exercises

30%

(757/2561)

2

Platelet-rich plasma (PRP) injections

6%

(146/2561)

3

Arthroscopic lysis of adhesions and bursectomy

1%

(15/2561)

4

Reassurance and a gentle stretching program as symptoms allow

63%

(1612/2561)

5

Manipulation under anesthesia

1%

(20/2561)

ML 3

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PREFERRED RESPONSE 4

(SBQ06BS.44) Which of the following statements is true regarding the anatomical boundaries of the rotator interval in the shoulder? Review Topic

QID: 2556
1

Superior border is defined by the biceps long head tendon

8%

(32/397)

2

Inferior border is defined by anterior band of inferior glenohumeral ligament

6%

(24/397)

3

Contains the axillary pouch which is a common site for intra-articular loose bodies

2%

(6/397)

4

Superior border is defined by anterior edge of suprapinatus tendon

76%

(300/397)

5

Inferior border is defined by middle glenohumeral ligament

8%

(32/397)

ML 2

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PREFERRED RESPONSE 4
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