Adhesive Capsulitis

 most commonly referred to as frozen shoulder (FS), is an idiopathic disease with 2 principal
characteristics: pain and contracture.

 In 1934, Codman stated, "This entity [FS] is difficult to define, difficult to treat, and difficult to explain
from the point of view of pathology." Codman's statement continues to hold true today.

 In 1992, the American Shoulder and Elbow Surgeons Society agreed on the following definition of FS by
consensus: a condition of uncertain etiology that is characterized by clinically significant restriction of
active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder.

Pain

 Shoulder pain associated with FS is progressive and initially felt mostly at night or when the shoulder is
moved close to the end of its range of motion (ROM).

 It can be caused by certain combined movements of the shoulder, such as abduction and external
rotation (eg, grooming one's hair, reaching for a seatbelt overhead) or extension and internal rotation
(eg, reaching for a back pocket or bra strap).

 In approximately 90% of patients with FS, this pain usually lasts 1-2 years before subsiding.

Contracture

 The second principal characteristic of FS is progressive loss of passive ROM (PROM) and active ROM
(AROM) of the glenohumeral joint in a capsular pattern

Pathophysiology

 Evaluation of anatomic, histologic, and surgical specimens from subjects affected by idiopathic FS
demonstrates that the glenohumeral joint synovial capsule is often involved in this disease process.

 active process of hyperplastic fibroplasia and excessive type III collagen secretion that lead to soft-tissue
contractures of the aforementioned structures (ie, the coracohumeral ligament, soft tissues of rotator
interval, the subscapularis muscle, the subacromial bursae)

Frequency

 Shoulder pain is the third most common cause of musculoskeletal disability after low back pain (LBP)
and neck pain.

 The prevalence of FS in the general population is reported to be 2%, with an 11% prevalence in
unselected individuals with diabetes.

 For patients with type I diabetes, the risk of developing FS in their lifetime is approximately 40%.

 FS may affect both shoulders, either simultaneously or sequentially, in as many as 16% of patients.

 The frequency of bilateral FS is higher in subjects with diabetes than in those without diabetes.

 In 14% of patients, while FS still is active in the initial shoulder, the contralateral shoulder also becomes
affected.
 Contralateral FS usually occurs within 5 years of disease onset. A relapse of FS in the same shoulder is
unusual.

 FS most frequently occurs in subjects with hyperthyroidism and hypertriglyceridemia.

 Although various authors report that heart disease, tuberculosis, and many other medical conditions are
associated with FS

 FS will undoubtedly become increasingly common as the baby-boom generation ages, because this
condition most frequently occurs in the fifth and sixth decades of life.

 Patients who present with an idiopathic FS when they are younger than 40 years should definitely be
examined to rule out occult diabetes, hyperthyroidism, hypertriglyceridemia, or concomitant neurologic
or systemic rheumatologic disorder affecting the upper extremity.

 FS affects women more frequently than men, with a female-to-male ratio of about 1.4:1. Menopause is
often reported as a cause of FS in women.

 mean ages of onset are 52 years for women and 55 years for men

3 clinical phases typically characterize FS:

 1. Phase 1 - The painful phase; the patient describes an insidious onset of predominantly nocturnal
pain, usually without a precipitating factor.

- The pain is not related to activity, although the farthest ROM can increase the pain. As the
disease progresses, patients have pain at rest.
- In this phase, which lasts 2-9 months, ROM is not restricted, and the diagnosis may remain
unclear.

 2. Phase 2 - The frozen, or adhesive, phase; the pain from phase 1 can persist, although it may
decrease.

 - Progressive limitation in ROM occurs in a capsular pattern (that is, in all directions). Normal
daily activities can be severely affected. -Hallmarks of this phase are an inability
to move at great amplitude and an inability to move on the affected side.
 -Diagnosis is easier in this phase than in phase 1. Although phase 2 is reported to last 3-9
months, it can persist longer than this.

 3. Phase 3 - The thawing, or regressive, phase; pain progressively decreases, and limitations in ROM
progressively increase over 12-24 months.

- approximately 40% of patients have slight, persistent limitations in ROM, only 10% have
clinically significant long-term functional limitations.

 Careful neurologic examination should be conducted in all patients presenting with signs and symptoms
associated with FS.

 Patients who have a history of smoking should undergo chest radiography with apical views to rule out a
Pancoast tumor irritating the brachial plexus, which can cause FS.
 All patients should receive a thorough neurologic examination of the upper extremities and neck to rule
out cervical radiculopathy and brachial plexopathy.

 Care also should be taken to look for signs of Parkinson disease, because the prevalence of shoulder
pain in patients with this treatable condition is 4-5 times that of the healthy population.

 Furthermore, shoulder pain often is an early manifestation of Parkinson disease, and it sometimes
precedes the tremor by many years.10

 Proper and complete musculoskeletal and integumentary examination should be performed to rule out
concomitant systemic rheumatologic, inflammatory, metastatic, or infectious disorders.

 Clinicians should also take the time to properly examine the thyroid gland to rule out concomitant
hyperthyroidism.

 Physicians should remain alert to signs of unsuspected diabetes, which may be present in approximately
25% of subjects presenting with FS.

Work-up

 Laboratory Studies

 The scientific literature shows an elevated incidence of diabetes, hyperthyroidism, and

hypertriglyceridemia in patients with FS.

 Lequesne and colleagues found that 28% of 60 new patients who presented with idiopathic FS had
unsuspected diabetes.11
 This association should prompt possible testing of thyroid-stimulating hormone (TSH), serum
triglyceride, and fasting blood sugar levels in most patients, particularly those presenting with
bilateral disease and patients presenting with FS who are younger than 45 years.

Imaging Studies

 Radiologic studies

 In general, idiopathic FS is considered a clinical diagnosis that does not require confirmation
with radiologic imaging.

 Current radiologic studies do not seem to confer any useful information, prognostic or
otherwise, that changes the way the patient is treated.

 For the moment, the principal utility of these tests is in ruling out concomitant conditions that may
influence the treatment of an individual patient

 Plain radiography

 All patients presenting with FS should undergo plain radiography of the shoulder, with the
acquisition of soft-tissue views of the rotator cuff to rule out a septic or metastatic process.
  A plain radiograph may also show evidence of a large calcification of the rotator cuff in the
painful resorptive phase, an avascular necrosis of the humeral head (that is, Milwaukee
shoulder), or a Charcot joint.

 Gallium nuclear scanning - Patients who are immunocompromised, as well as those who abuse
intravenous (IV) drugs, should undergo gallium nuclear scanning to rule out a septic joint.

 Arthrography of the glenohumeral joint

 arthrography is used mostly to treat FS, rather than to diagnose the condition.

 The injection of contrast medium into the glenohumeral joint helps to determine its volume and
configuration. The normal volume of the joint is 13 mL. In FS, the volume can be reduced to 5-8
mL.
99m
 Tc methylene diphosphonate (MDP) bone scanning

 -In general, the problem with bone scans in the practice of musculoskeletal medicine is that they
are highly sensitive but not specific

 Other studies - Computed tomography (CT) scanning, CT arthrography, ultrasonography, and magnetic
resonance imaging (MRI) are sensitive imaging modalities that depict specific signs for FS. However, use
of these modalities is rarely indicated.

 Treatment

Rehabilitation Program

 -Physical Therapy
o ---Although studies have shown the efficacy of physical therapy, no current evidence has
suggested that physical therapy alone improves function in the treatment of FS.
o ---physical therapy associated with an intra-articular injection of corticosteroid improves
function and ROM more rapidly than does intra-articular corticosteroid injection alone

 Therapeutic exercises

- Therapeutic exercises that have been studied include articular stretching and pulley therapy.
- Passive articular stretching exercises improve ROM.

 Manual therapy

 ---Data from 2 studies support the use of manual therapy to improve ROM in the short term.

 Physical modalities

 Many electroanalgesic and thermoanalgesic modalities are often used in physical therapy.

 Occupational Therapy

 Patients with severe FS may benefit from a referral to an occupational therapist for assistance
and instruction in performing activities of daily living (ADLs).
 The occupational therapist helps the patient learn how to use adaptive equipment and suggest
home and workplace modifications that may be necessary and beneficial for completing
professional activities and routine daily tasks (eg, dressing, bathing, grooming)

 Surgical Intervention

 Duplay, the first person to describe the syndrome of FS, in 1872, proposed treating this
condition with manipulation of the glenohumeral joint, with the patient under general
anesthesia.

 --some orthopedic surgeons continue to practice this technique, the benefits of

this approach have not been demonstrated in controlled clinical trials.

 A 2009 study by Jacobs et al also found no evidence that manipulation provides

a better treatment outcome in FS.

 Various improvements in surgical techniques, such as the advent of controlled capsular release
by using arthroscopic access to the anterior glenohumeral joint capsule and the coracohumeral
ligament, appear to offer promising treatments.

 However, the effectiveness of these surgical techniques has yet to be demonstrated in

controlled clinical trials

 Considering the favorable prognosis for patients with idiopathic FS, surgical intervention should
probably be reserved for rare patients whose condition does not respond to maximal
conservative modalities implemented over a sufficient period of time.