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Adhesive Capsulitis (Frozen Shoulder)
Introduction
Adhesive capsulitis, commonly known as frozen shoulder, is characterized by painful and progressive shoulder motion loss due to fibrotic joint capsule changes.[1][2] This condition predominantly affects middle-aged adults, especially those with endocrine disorders such as diabetes or thyroid dysfunction, which can predispose individuals to more severe forms of the disease.[3] Despite its commonality, the pathophysiology remains only partially understood, and the condition is often under-recognized, leading to delays in treatment and prolonged disability. The persistent nature of adhesive capsulitis and its significant effect on a patient's daily functioning emphasizes the critical need for expedient diagnosis, treatment, and a comprehensive care strategy involving multiple medical specialties.[4]
Etiology
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Etiology
Adhesive capsulitis is categorized into primary and secondary types based on etiology.
Primary Adhesive Capsulitis
This form occurs without an obvious precipitating factor and is often considered idiopathic. and is thought to arise from an intrinsic inflammation leading to fibrotic changes within the shoulder capsule. Though the exact cause is unknown, it is frequently associated with systemic conditions such as diabetes mellitus and thyroid disorders, suggesting an underlying systemic inflammatory or autoimmune component.[5][6]
Secondary Adhesive Capsulitis
This form results from an external event or condition directly affecting shoulder mobility. Common causes include:
- Trauma: A significant injury to the shoulder that leads to immobilization can precipitate adhesive capsulitis.
- Surgery: Postoperative complications, especially shoulder or chest wall surgeries, can lead to the development of adhesive capsulitis.[7]
- Prolonged immobilization: Extended immobilization after injury or surgery can lead to stiffening of the joint capsule.[8]
Clinical reviews suggest that other risk factors, such as prolonged hyperglycemia in diabetics, hormonal imbalances in thyroid disorders, and possibly an increased immune response, play roles in the development of the condition.[4]
Epidemiology
Adhesive capsulitis exhibits specific epidemiological patterns that highlight its impact on various population segments:
- Prevalence: Adhesive capsulitis affects approximately 2% to 5% of the general population.[9]
- Age of onset: The mean age of onset is typically around 55. This population often corresponds with an increase in the incidence of various systemic conditions like diabetes and thyroid disorders.[10]
- Gender disparity: Women have a slight predominance, with a ratio of about 1.4:1 compared to men. This sex disparity may be related to hormonal factors or differences in immune system functioning.
- Affected side: The nondominant hand is more often affected. This observation might relate to differential use patterns and compensatory behaviors affecting biomechanics and physiological stress responses.[7]
- Impact of comorbid conditions: Individuals with autoimmune and endocrine comorbidities, such as thyroid disorders and diabetes mellitus, are more prone to developing adhesive capsulitis. These conditions alter the body's inflammatory and fibrotic responses, exacerbating the progression and symptoms of adhesive capsulitis.[11]
- Influence of diabetes duration: The duration of the disease can significantly influence treatment outcomes for patients with diabetes. Longer durations of diabetes are often associated with poorer outcomes in managing adhesive capsulitis, likely due to the chronic hyperglycemic environment affecting collagen elasticity.[7]
Pathophysiology
The pathophysiology of adhesive capsulitis remains uncertain and involves a complex interplay between inflammation and fibrosis. Initially, an inflammatory response leads to pain and limited motion.[9] Subsequently, fibrotic changes occur within the joint capsule, particularly the rotator interval, leading to thickening of the coracohumeral ligament and contraction of the joint capsule.[12] These changes are often visualized in imaging studies, demonstrating reduced joint capsule volume and thickening of the synovial lining. The fibrotic process is mediated by various cytokines and growth factors, which contribute to the proliferation of fibroblasts and excessive collagen deposition, further restricting shoulder mobility.[13]
Histopathology
Histologically, adhesive capsulitis is characterized by synovial hyperplasia, angiogenesis, and eventual joint capsule fibrosis.[4][14] These changes lead to a palpably thickened and contracted joint capsule, significantly restricting both active and passive range of motion. The pathophysiology involves both inflammation and fibrosis, and the condition passes through several stages, including an initial inflammatory phase, a fibrotic phase characterized by increasing stiffness and limited range of motion, and a thawing or regression phase, where gradual improvement in shoulder mobility occurs.[15] The duration of each stage can vary among individuals, and arthroscopic findings provide visual evidence of the pathological changes occurring within the joint.[8][16] Arthroscopic studies of the affected shoulder show:
- Subacromial fibrosis: The presence of fibrous tissue and adhesions in the subacromial space leads to restricted movement and impingement of the shoulder structures.[17][18]
- Proliferative synovitis: The synovium lining the joint capsule shows signs of excessive proliferation and inflammation, which contributes to the thickening of the synovial tissue.
- Capsular thickening: The joint capsule thickens and fibroses, leading to shoulder joint stiffness and a loss of range of motion.
History and Physical
The history of patients with adhesive capsulitis typically involves a gradual onset of shoulder pain that intensifies and restricts motion over weeks to months.[19] This pain may not initially be severe but typically worsens, impacting daily activities such as dressing, reaching, or sleeping. Patients often report an initial period of pain before stiffness sets in. However, as the condition progresses, the stiffness becomes more prominent and the pain transitions to a constant dull ache, with sharp pains with sudden movements or when reaching extremes of motion. This condition can persist from a few months to 2 to 3 years.[15][20][21]
A key clinical sign is the marked reduction in both active and passive range of motion. This includes difficulty with flexion, abduction, external rotation, and internal rotation.[12] The typical pattern of range of motion loss starts with external rotation, followed by abduction, internal rotation, and flexion. This restriction in movement is frequently accompanied by pain, which may prevent a thorough examination. Patients will have diffuse tenderness around the joint upon palpation. Despite this tenderness and limited motion, distal neurological function remains intact, helping differentiate adhesive capsulitis from other conditions, such as neurological impairments or more extensive rotator cuff injuries.[15][22] Special tests such as the Neer and Hawkins tests for impingement and Speed test for biceps tendinopathy often yield positive results, suggesting the involvement of surrounding structures. In severe cases, there may be an observable loss of the natural arm swing during walking and signs of muscle wasting due to disuse or compensatory behavior to avoid pain.[9][22]
Evaluation
The diagnosis of adhesive capsulitis is primarily clinical. A detailed patient history and physical examination are required, and a significant reduction in shoulder mobility in multiple planes is typically observed. Further evaluation may include:
Labs: Routine laboratory testing is not indicated for diagnosing adhesive capsulitis as it is primarily a clinical diagnosis. However, if an underlying systemic condition like diabetes or thyroid disease is suspected to contribute to the presentation, appropriate blood tests may be conducted. These tests help identify any underlying inflammatory or endocrine conditions that could mimic or exacerbate the symptoms of adhesive capsulitis.[23]
Imaging: A shoulder x-ray is often performed to rule out bony abnormalities. Magnetic resonance imaging may show a thickened coracohumeral ligament, rotator interval synovitis, or a noticeable decrease in the size of the axillary pouch.[10] These findings are not definitive for adhesive capsulitis, but help confirm the diagnosis and assess the severity of intra-articular involvement. Advanced imaging techniques can also assess the efficacy of therapeutic interventions by monitoring changes in the tissue composition of the joint capsule over time.[24][25]
Diagnostic injection: Diagnostic injection testing involves administering a local anesthetic, typically 1% lidocaine, into the subacromial space. This helps differentiate between adhesive capsulitis and other pain sources like subacromial bursitis or rotator cuff tendinopathy. In adhesive capsulitis, the restriction of range of motion persists even after the anesthetic injection. In other conditions, there may be an improvement in pain and increased range of motion following the injection.[20][24][20][26][27]
Differential Diagnosis
The differential diagnosis for this condition is detailed below in Table. Conditions Similar to Adhesive Capsulitis.
Table. Conditions Similar to Adhesive Capsulits
| Condition | Symptoms | Testing | Characteristic Clinical Features |
| Cervical radiculopathy | Neck pain, radiating arm pain, numbness | MRI of cervical spine, nerve conduction studies | Involvement of neck with specific nerve root patterns; radiating pain follows dermatomal pattern [22] |
| Acromioclavicular joint arthrosis | Joint pain at top of shoulder, tenderness | X-ray shows joint degeneration, osteophytes | Localized pain at AC joint, worsened with cross-body movements |
| Bicep tendinopathy | Anterior shoulder pain, pain with flexion | MRI or ultrasound showing tendon changes, Speed's test | Pain specifically in the bicep tendon region, positive Speed’s test |
| Glenohumeral arthritis | Deep joint pain, stiffness, crepitus | X-ray or MRI shows joint space narrowing, osteophytes, subchondral sclerosis | More constant joint pain, involvement in other joints, radiographic joint changes |
| Fracture | Acute pain, swelling, history of trauma | X-ray or CT scan | Trauma history, localized pain, deformity, immediate onset |
| Calcifying Tendinitis/Synovitis | Severe, acute pain, motion limitation | X-ray shows calcifications, ultrasound for tendon integrity | Acute flare-ups of pain, visible calcifications on x-ray |
| Malignancy | Progressive pain, night pain, weight loss | MRI, biopsy if needed | Systemic symptoms, progressive worsening without trauma |
| Rotator cuff Impingement | Pain with overhead activities | Positive impingement tests, MRI or ultrasound showing tendon damage | Pain primarily with overhead activities, positive impingement signs |
| Polymyalgia rheumatica | Bilateral shoulder pain, morning stiffness | Elevated ESR and CRP, clinical response to steroids | Systemic involvement, age > 50, rapid response to steroids |
| Shoulder impingement syndrome | Pain with arm elevation, night pain | Positive impingement signs, MRI or ultrasound | Pain with specific movements, often younger patients, no global stiffness [28] |
AC, acromioclavicular joint; CRP, C-reactive protein; CT, computed tomography; ESR, erythrocyte sedimentation rate; MRI, magnetic resonance imaging
Staging
The clinical course of adhesive capsulitis varies significantly among individuals and is influenced by personal factors and treatment efficacy.[29] While some patients regain full range of motion within months, others may experience a protracted course lasting up to 3 years. Disease progression is described in 3 clinical phases.[30] Each varies in duration and is characterized by different symptoms.
The initial phase, known as the freezing phase, is marked by diffuse, disabling shoulder pain that worsens at night with increasing stiffness. The pain intensifies as the range of motion begins to decrease. This phase typically lasts from 2 to 9 months. The intermediate frozen phase is characterized by reduced pain intensity, and persistent stiffness emerges as the primary concern. Capsular rigidity progressively restricts the shoulder's range of motion across all planes, significantly impacting functionality. This phase generally lasts between 4 to 12 months. Last, the thawing phase is characterized by gradual pain reduction and mobility restoration.
Prognosis
The prognosis for patients with adhesive capsulitis is generally good with early and appropriate management, including physical therapy, anti-inflammatory medications, and corticosteroid injections. Approximately 80% of patients regain near-normal or normal shoulder function with proper treatment. Early intervention can lessen the severity and duration of symptoms and improve outcomes.[10][29] While the prognosis is generally favorable, about 10% to 20% of patients experience residual symptoms, including stiffness and discomfort.
Persistent symptoms can affect quality of life and range of motion. Individuals with comorbid conditions such as diabetes mellitus or thyroid dysfunction commonly have longer and more severe courses of adhesive capsulitis and have a less favorable prognosis. In cases where conservative treatments fail, surgical interventions such as capsular release or manipulation under anesthesia are considered. These procedures generally have good outcomes, but like all surgeries, they come with risks and require postoperative rehabilitation to regain full function.[14]
Complications
Complications vary depending on the stage of the disease and the treatment approach. Residual shoulder pain and stiffness are the most common issues, often persisting even after the condition has resolved.[31] Immobility causes the shoulder to become deconditioned and more vulnerable to additional injury such as labral tears resulting from excessive stress on the shoulder capsule and adjacent structures. Secondary injury can also occur with surgical procedures intended to restore mobility, such as manipulation under anesthesia. The force applied during this procedure can cause humeral fractures and biceps or subscapularis tendon ruptures.[21][32][33] Furthermore, the condition and its treatment can potentially lead to more severe complications, including glenohumeral joint dislocation and rotator cuff tears.[10]
Deterrence and Patient Education
Patient education involves informing patients about the nature of the condition, the significance of timely intervention, and effective strategies to manage symptoms.[34][35][36] Understanding this condition's natural progression and self-limiting nature is crucial for setting realistic expectations and improving patient compliance with treatment protocols.[37][38]
Explanation of the Condition
Provide patients with a clear and concise explanation of adhesive capsulitis, and its characteristic pain and stiffness in the shoulder joint. This foundational understanding helps patients better engage with their treatment plans.[29]
Natural Course and Timeline
Educate patients about the 3 phases of adhesive capsulitis: freezing, frozen, and thawing. This helps patients understand that recovery can take several months to years to resolve completely, which can be instrumental in managing expectations and reducing anxiety about the recovery process.
Preventive Measures
Preventive strategies include quickly recovering shoulder mobility after injury or surgery to prevent stiffness. Effectively managing underlying systemic diseases such as diabetes is also important.
Range of Motion Exercises
Patients should understand the importance of regular participation in a customized exercise program. Proprioceptive neuromuscular facilitation exercises effectively treat adhesive capsulitis impairments.[36]
Rehabilitation Techniques
Rehabilitation techniques should be applied relative to the patient's age, activity level, and comorbid conditions. While widely employed, techniques like ultrasound, electrical stimulation, and manual therapy require additional research to validate and standardize their application.[35]
Collaboration in Care
Close collaboration between therapists and clinicians is crucial to monitoring patient progress and addressing setbacks promptly. Therapists should adhere to specific rehabilitation protocols, particularly post-operatively, as orthopedic physicians prescribe. This approach ensures treatment consistency and alignment with current clinical guidelines.
When to Seek Further Medical Help
Patients should be informed about the signs that warrant further medical evaluation, such as worsening symptoms, new-onset weakness, or numbness in the arm, which suggest pathologies other than adhesive capsulitis.
Pearls and Other Issues
Key facts to keep in mind about adhesive capsulitis are as follows:
- The hallmark trait of adhesive capsulitis is a significant loss of passive and active range of motion, especially shoulder external rotation.
- Although the exact pathophysiology is unknown, it is widely believed to originate from inflammation within the joint capsule and synovial fluid.
- The diagnosis is based on clinical evaluation and patient history. Imaging studies are not indicated for diagnosing adhesive capsulitis; however, a shoulder x-ray or magnetic resonance imaging may be used to rule out pathoanatomy.
- Laboratory testing is not indicated for diagnosing adhesive capsulitis, but it can be used to investigate potential underlying systemic diseases that contribute to or mimic its symptoms.
- Adhesive capsulitis is a self-limiting condition with a positive prognosis, particularly with timely diagnosis and treatment. Physical therapy serves as the cornerstone of treatment.
Enhancing Healthcare Team Outcomes
Effective management of adhesive capsulitis requires a collaborative approach among a diverse healthcare team consisting of cllinicians, nurses, physical therapists, and occupational therapists. The primary care clinician is responsible for initial evaluation and management decisions. They must understand the 3 phases of adhesive capsulitis and recognize when conservative measures have failed to promptly refer to specialists such as orthopedic surgeons to discuss potential surgical intervention. Physical therapists play a critical role in reducing pain and improving mobility through individualized exercises, while occupational therapists provide strategies to improve performance of daily activities affected by shoulder dysfunction. Patients must be informed about their condition to establish informed consent and empower them to assist in making treatment decisions.
Communication and collaboration among healthcare professionals is essential for optimizing treatment outcomes. This includes using shared electronic health records and maintaining open communication, ensuring all team members are updated on the patient's progress and treatment responses. Regular team meetings and continued professional development, such as workshops on the latest treatment techniques, can enhance team performance and ensure patient safety and satisfaction.
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