Adhesive capsulitis of shoulder

Template:Adhesive Capsulitis of Shoulder Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Marufa Marium, M.B.B.S[2]

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Synonyms and keywords: Frozen shoulder syndrome; Adhesive capsulitis; Duplay Bursitis, Scapulohumeral periarthritis; Arthofibrosis; Shoulder pain; Shoulder stiffness; Shoulder Capsulitis.

Overview

Adhesive capsulitis is an inflammatory insult to glenohumeral joint limiting active and passive range of motion due to pain and stiffness of shoulder joint. The active and passive range of motion is debilitated due to inflammation and fibrosis of adhesive bursa due to primary and secondary causes.

Historical Perspective

• Adhesive capsulitis was first discovered by Simon Emmanuel Duplay, a French surgeon, in 1872 who introduced the term 'scapulohumeral periarthritis' to identify painful shoulder with normal preservation of imaging findings. In 1934 Earnest Codman termed it as Frozen Shoulder' as there was loss of range of motion at shoulder joint. Later in 1945, due to the involvement of inflammation of capsule leading to fibrosis of bursa was elaborated by Julius Neviaser, he named it 'Adhesive capsulitis'.

Classification

• Adhesive Capsulitis may be classified according to etiology into two groups:

• Primary or Idiopathic:

• • Adhesive capsulitis can occur spontaneously without concurrent shoulder joint abnormality or inciting factors

• Secondary:

• • Adhesive capsulitis can present due to preexistent shoulder joint dysfunction for instances glenohumeral joint dislocation with fracture of periarticular region, joint trauma, arthroscopic surgery to shoulder joint, arthroplasty or rotator cuff injury repair.

Pathophysiology

• The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
• The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
• On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
• On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Causes

Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] include [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

Differentiating [disease name] from other Diseases

For further information about the differential diagnosis, click here.

Epidemiology and Demographics

• The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
• In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

• Patients of all age groups may develop [disease name].

• [Disease name] is more commonly observed among patients aged [age range] years old.
• [Disease name] is more commonly observed among [elderly patients/young patients/children].

Gender

• [Disease name] affects men and women equally.

• [Gender 1] are more commonly affected with [disease name] than [gender 2].
• The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

Race

• There is no racial predilection for [disease name].

• [Disease name] usually affects individuals of the [race 1] race.
• [Race 2] individuals are less likely to develop [disease name].

Risk Factors

• Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

Natural History, Complications and Prognosis

• The majority of patients with [disease name] remain asymptomatic for [duration/years].
• Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
• If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
• Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
• Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

• The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:

• [criterion 1]
• [criterion 2]
• [criterion 3]
• [criterion 4]

Symptoms

• [Disease name] is usually asymptomatic.
• Symptoms of [disease name] may include the following:

• [symptom 1]
• [symptom 2]
• [symptom 3]
• [symptom 4]
• [symptom 5]
• [symptom 6]

Physical Examination

• Patients with [disease name] usually appear [general appearance].
• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Laboratory Findings

• There are no specific laboratory findings associated with [disease name].

• A [positive/negative] [test name] is diagnostic of [disease name].
• An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
• Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• [Disease name] may also be diagnosed using [diagnostic study name].
• Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Differentiating Adhesive Capsulitis of Shoulder from other Diseases

• Brachial plexus injury
• Caplan's Syndrome
• Cerebrovascular accident
• Cervical spinal cord injury
• Diabetes Mellitus
• Felty's Syndrome
• Hyperthyroidism
• Hypotriglyceridemia
• Parkinson's Disease
• Reiter's Syndrome
• Repetative movements
• Rheumatic Fever
• Rheumatoid Arthritis
• Still's Disease

Epidemiology and Demographics

It has an incidence of 2,400 out of every 100,000 patients per year.

Risk Factors

Most of the time there is no cause for frozen shoulder. Risk factors include:

• Cervical disk disease of the neck
• Diabetes
• Shoulder injury
• Shoulder surgery
• Open heart surgery
• Thyroid problems

Natural History, Complications and Prognosis

Complications

• Stiffness and pain continue even with therapy.
• The arm can break if the shoulder is moved forcefully during surgery.

Prognosis

Treatment with physical therapy and NSAIDs will usually restore motion and function of the shoulder within a year. Even untreated, the shoulder can get better by itself in 24 months.

After surgery restores motion, you must continue physical therapy for several weeks or months to prevent the frozen shoulder from returning. Treatment may fail if you cannot keep up with physical therapy.

Diagnosis

History and Symptoms

Movement of the shoulder is severely restricted. The condition is sometimes caused by injury that leads to lack of use due to pain but also often arises spontaneously with no obvious preceding trigger factor. These seemingly spontaneous cases are usually referred to as Idiopathic Frozen Shoulder. Rheumatic disease progression and recent shoulder surgery can also cause a pattern of pain and limititation similar to frozen shoulder. Intermittent periods of use may cause inflammation.

Abnormal bands of tissue (adhesions) grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally helps the shoulder joint move by lubricating the gap between the humerus (upper arm bone) and the socket in the scapula (shoulder blade). It is this restricted space between the capsule and ball of the humerus that distinguishes adhesive capsulitis from a less complicated, painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or who have been in an accident, are at a higher risk for frozen shoulder. Adhesive capsulitis has been indicated as a possible adverse effect of some forms of highly active antiretroviral therapy (HAART). The condition rarely appears in people under 40 years old and (at least in its idiopathic form) is much more common in women than in men (70% of patients are women aged 40-60). Frozen shoulder in diabetic patients is generally thought to be a more troublesome condition than in the non-diabetic population. If a diabetic patient develops frozen shoulder then the time to full recovery is often prolonged from the usual 12 month period.

Physical Examination

With a frozen shoulder, one sign is that the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. People complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. A doctor, or therapist (occupational, massage or physical), may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can also be diagnosed if limits to the active range of motion (range of motion from active use of muscles) are the same or almost the same as the limits to the passive range of motion (range of motion from a person manipulating the arm and shoulder).

Physicians have described the normal course of a frozen shoulder as having three stages:

• Stage one: In the "freezing" or painful stage, which may last from six weeks to nine months, the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.

• Stage two: The "frozen" or adhesive stage is marked by a slow improvement in pain, but the stiffness remains. This stage generally lasts four months to nine months.

• Stage three: The "thawing" or recovery, during which shoulder motion slowly returns toward normal. This generally lasts five months to 26 months.

MRI

An arthrogram or an MRI scan may confirm the diagnosis - although in practice this is rarely required. Most orthopedic specialists make the diagnosis of frozen shoulder by recognizing the typical pattern of signs and symptoms.

Shown below are MRI images from a patient with adhesive capsulitis.

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Treatment

Medical Therapy

Management of this disorder focuses on restoring joint movement and reducing shoulder pain. Usually, it begins with nonsteroidal anti-inflammatory drugs (NSAIDs) and the application of heat, followed by gentle stretching exercises. These stretching exercises, which may be performed in the home with the help of a physical, massage or occupational therapist, are the treatment of choice. In some cases, transcutaneous electrical nerve stimulation (TENS) with a small battery-operated unit may be used to reduce pain by blocking nerve impulses. The next step often involves one or a series of steroid injections (up to six).

If these measures are unsuccessful, the doctor may recommend manipulation of the shoulder under general anesthesia to break up the adhesions. Surgery to cut the adhesions is only necessary in some cases.

Alternative medicine treatments include:

• Accupuncture for pain
• Holistic procedures such as the Bowen Technique

Primary Prevention

To prevent the problem, a common recommendation is to keep the shoulder joint fully moving to prevent a frozen shoulder. Often a shoulder will hurt when it begins to freeze. Because pain discourages movement, further development of adhesions that restrict movement will occur unless the joint continues to move full range in all directions (adduction, abduction, flexion, rotation, and extension). Therapy will help one continue movement to discourage freezing and warm it. A medical doctor referral is needed before occupational or physical therapy can begin under law in most US states. Medical referral is not required for physical or occupational therapy in most Canadian provinces.

Related Chapters

• Calcific Tendonitis

External Links

• "Adhesive Capsulitis: A Sticky Issue" from American Family Physician, 1999

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