Continuing Education Activity

Adhesive capsulitis, also known as frozen shoulder, is an inflammatory condition characterized by shoulder stiffness, pain, and significant loss of passive range of motion. Long-term disability has been reported at ten to twenty percent in patients and the persistence of symptoms at thirty to sixty percent. This activity reviews the evaluation and management of adhesive capsulitis and highlights the role of the interprofessional team in caring for patients with this condition.

Objectives:

• Describe common presenting signs and symptoms of adhesive capsulitis.
• Review how to evaluate a patient for adhesive capsulitis.
• Identify treatment considerations for adhesive capsulitis.
• Outline interprofessional team strategies to improve care coordination and outcomes for patients with adhesive capsulitis.

Introduction

Adhesive capsulitis, also known as frozen shoulder, is an inflammatory condition characterized by shoulder stiffness and pain. The American Academy of Orthopedic Surgeons defines adhesive capsulitis as “a condition of varying severity characterized by the gradual development of global limitation of active and passive shoulder motion where radiographic findings other than osteopenia are absent.”

The majority of patients have significant loss of passive range of motion, a feature that is crucial for diagnosis.[1][2][3]

Etiology

Adhesive capsulitis can be classified as either primary or secondary. The primary disease typically has an insidious onset and is idiopathic and is often associated with other diseases such as diabetes mellitus, thyroid disease, drugs, hypertriglyceridemia, or cervical spondylosis.[4][5]

The secondary disease typically follows trauma or injuries to the shoulder. Common injuries include rotator cuff tears, fractures, surgery, or immobilization.

Epidemiology

Adhesive capsulitis has a prevalence of approximately two to five percent in the general population. The mean age of onset is typically 55 years of age. There is a slightly greater predominance in females (1.4:1). Usually, the non-dominant hand is affected. Interestingly, several autoimmune comorbid conditions have been shown to predispose patients to this condition, including thyroid disorders and diabetes mellitus. Additionally, patients with diabetes typically have worse treatment outcomes depending on the duration of their diabetes.[6]

Pathophysiology

The exact pathophysiology of adhesive capsulitis is unknown. The most commonly accepted hypothesis states that inflammation initially occurs within the joint capsule and synovial fluid. The inflammation is followed by reactive fibrosis and adhesions of the synovial lining of the joint. The initial inflammation of the capsule leads to pain, and the capsular fibrosis and adhesions lead to a decreased range of motion.

Histopathology

During arthroscopy, the following may be seen:

• Subacromial fibrosis
• Proliferative synovitis
• Capsular thickening

History and Physical

Patients with adhesive capsulitis usually present with progressively worsening shoulder pain over weeks to months, followed by significant limitation in shoulder motion. Disease progression is described in 3 clinical phases:

• Phase 1: The painful phase. Development of diffuse and disabling shoulder pain is initially worse at night but then progresses to pain at rest. Associated with increasing stiffness. It can last from two to nine months.
• Phase 2: The frozen or adhesive phase. This period is characterized by progressive limitation in ROM in all shoulder planes but with the pain gradually becoming less pronounced. It can last from four to 12 months.
• Phase 3: The thawing or regression phase. The recovery phase where there is a gradual return of the range of motion. It takes 12 to 24 months for the complete return of range of motion (ROM).

Evaluation

During a physical exam, patients will often have a decreased glenohumeral range of motion and associated pain with testing. Pain will often limit a complete and thorough physical exam. Typically, there is a significant reduction in the active and passive range of motion in 2 or more planes of motion compared to the unaffected side. Usually, the range of motion is lost in the following order: external rotation, abduction, internal rotation, forward flexion. When using special tests of the shoulder, the Neer and Hawkins tests for impingement and the Speed’s test for biceps tendinopathy are positive. Diagnosis is clinical and based on history and physical exam findings as described above.[7]

There is no laboratory testing indicated for diagnosis. If there is a concern for underlying systemic disease, test as needed.

Imaging is not indicated. The diagnosis of adhesive capsulitis is primarily clinical. If there is a concern of an alternative diagnosis, such as evaluating for a fracture, then imaging such as a shoulder X-ray may be useful.

The injection test can be performed if a clinician is uncertain of the etiology of shoulder pain based on history and exam. The subacromial space is injected with an anesthetic, typically 5 ml of 1% lidocaine. In patients with adhesive capsulitis, the ROM limitations and pain will persist after the injection. In patients with subacromial pathology (rotator cuff tendinopathy or subacromial bursitis) will show an improvement of pain and improved range of motion.

Treatment / Management

In most cases, adhesive capsulitis is a self-limited disease with high rates of spontaneous recovery within 18 to 30 months. Treatment is focused on symptomatic relief and improving ROM.[8][9] There are limited studies that guide treatment management. The following are some viable treatment options:

• NSAIDs: During the initial phase NSAIDs can be used to aid with pain control.
• Physical therapy: Therapy has limited evidence supporting its benefit but patients often in the recovery phase may benefit from gentle range of motion exercises, stretching, and graded resistance training. These have been shown to reduce pain and increase function. Patients and providers should not allow vigorous rehab as that can lead to worsening symptoms.
• Oral corticosteroids: These provide short-term pain relief for improved ROM and function. The benefits often do not last longer than a few weeks, and the clinician should be cognizant of the side effects associated with oral steroid use.
• Intra-articular steroid injection: Injections have been shown to improve function, decrease pain, and increase ROM. Like oral steroids the duration of effects of steroid injections are limited as providers must be cognizant of side effects. Often patients who receive injections early in their disease course are more likely to obtain a benefit. Multiple injections can be given to provide symptomatic relief.
• Hydrosilation: In this treatment modality the joint is injected with saline and steroid to dilate the glenohumeral capsule. This has been shown to reduce pain and improve ROM and function in the short term. Current evidence shows no significant difference in outcomes when comparing hydrodilatation to intra-articular steroid injection.
• Manipulation under anesthesia: this is reserved for more refractory cases that do not respond to the modalities mentioned above. There is an increased risk of homers fractures.
• Surgical capsular release: This is reserved for refractory cases. Typically, if symptoms do not improve with conservative measures within 10 to 12 months referral to an orthopedic surgeon is recommended.

Indications for Surgery

• The patient fails a trial of prednisone or NSAIDs.
• No response to glenohumeral or subacromial injections
• No response respond to physical therapy

Contraindications for Surgery

• The patient has had an inadequate course of steroids or NSAIDs.
• The patient has not had any attempt at conservative therapy.
• There is an acute infection.
• The patient has a concomitant malignancy in the shoulder.
• The patient has a neurological deficit or nerve complaint originating from the cervical spine.

Differential Diagnosis

• Cervical radiculopathy
• Fracture
• Calcifying tendinitis/synovitis
• Malignancy
• Rotator cuff impingement
• Polymyalgia rheumatica
• Shoulder impingement syndrome

Complications

• Residual shoulder pain and/or stiffness
• Humeral fracture
• Rupture of the biceps and subscapularis tendons

Postoperative and Rehabilitation Care

The patient must enroll in a formal exercise program, irrespective of treatment.

Consultations

Once a diagnosis of a frozen shoulder is made, a physical rehabilitation clinician should be consulted.

Deterrence and Patient Education

Continue with exercise to prevent recurrence of symptoms.

Pearls and Other Issues

• Adhesive capsulitis, also known as frozen shoulder, is an inflammatory condition characterized by shoulder stiffness and pain.
• The majority of patients have significant loss of passive range of motion, a feature that is key for diagnosis.
• The exact pathophysiology is unknown. The most commonly accepted hypothesis states that inflammation initially occurs within the joint capsule and synovial fluid.
• There is no laboratory testing indicated for diagnosis. If there is a concern for underlying systemic disease, test as needed.
• Imaging is not indicated. The diagnosis of adhesive capsulitis is primarily clinical. If there is a concern of an alternative diagnosis, such as evaluating for a fracture, then imaging such as a shoulder X-ray may be useful.
• Frozen shoulder is a self-limiting condition and, if diagnosed early, has a favorable outcome. However, physical therapy must be a key part of treatment to achieve satisfactory outcomes.

Enhancing Healthcare Team Outcomes

Patients with a frozen shoulder may present to the primary caregiver. If needed an orthopedic referral may be appropriate. Specialty care nurses assist with evaluation and patient education.  It is important to know that a frozen shoulder is a self-limiting condition and if diagnosed early has a favorable outcome. Physical therapy must be a key part of treatment to achieve satisfactory outcomes. Several studies do show that in the long-term patients continue to have pain and or stiffness following conservative management. The interprofessional team has been shown to improve outcomes. [Level 5]

Long-term disability has been reported in 10 to 20% of patients and persistence of symptoms in 30 to 60%.