Also known as “frozen shoulder,” adhesive capsulitis (AC) is characterized by a painful, gradual loss in glenohumeral range of motion (ROM) resulting from progressive fibrosis and ultimate contracture of the glenohumeral joint capsule.1
The first known description of AC was by Duplay in 1872 in which he described a condition known as “Periarthritis Scapulohumeral.”2 In 1934 Codman described these cases as difficult to define, difficult to treat and difficult to explain from the point of view of pathology.3 Neviaser et al described the term “frozen shoulder” as a “waste-can diagnosis,” because it was often overdiagnosed on patients with a stiff and painful shoulder.1Conditions such as calcific tendonitis, bicipital tenosynovitis, glenohumeral and acromioclavicular arthritis, and rotator cuff tears can also potentially lead to a stiff and painful shoulder4-5 causing apparent limitation of active ROM, but they lack pathognomonic feature of true capsular contracture with subsequent restriction in passive ROM. These conditions are distinct from AC and, therefore, should not be diagnosed as AC. An accurate diagnosis is essential because treatment differs between the conditions.6
Epidemiology including risk factors and primary prevention
AC has a peak incidence between 40 to 60 years of age.7 It has been associated with conditions such as diabetes mellitus, thyroid dysfunction, Dupuytren’s contractures, autoimmune disease, and the treatment of breast cancer.1 The prevalence of AC in the general population is reported to be 3-5%, with a 20% prevalence in individuals with diabetes.7-8 20 to 30% of patients will report a history of trauma to the shoulder9-10, and one study reported that more than 60% of patients with AC had supraspinatus pathology.11 AC may affect both shoulders, either simultaneously or sequentially, in as many as 16% of patients.
AC is characterized by a thickened, tight glenohumeral joint capsule with adhesions obliterating the axillary fold. The fibrotic capsule adheres to itself and to the anatomic neck of the humerus. This leads to a minimal synovial fluid in the joint, and overall joint volume is diminished. Normal shoulder joint volumetric capacity ranges between 28 to 35 mL of injected fluid, whereas in AC, the joint accepts only 5 to 10 mL.1,3
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Based on the arthroscopic appearance of the joint capsule, four stages of disease have been described as it progresses from capsular inflammation to fibrosis1:
- Stage 1 (Preadhesive Stage) – consists of a fibrinous inflammatory synovitic reaction without adhesion formation. Patients typically have full ROM but report pain, usually at night. Symptoms are nonspecific, and often misdiagnosed.
- Stage 2 – is marked by acute adhesive synovitis with proliferation of the synovium leading to early formation of adhesions. Pain is the more prominent feature with active and passive movement, and there is mild loss in the ROM.
- Stage 3 (Maturation stage) – There is less pain than in the first 2 stages; However, passive and active ROM is significantly restricted.
- Stage 4 (Chronic stage) – Patients may have painless, limited ROM but pain occurs when the arm is suddenly moved beyond the limits of the scarred capsule.
Specific secondary or associated conditions and complications
Patients with AC demonstrate significant increases in scapular upward rotation on the affected side as compared to their nonaffected side. Secondary conditions might include cervical pain or thoracic pain.
2. ESSENTIALS OF ASSESSMENT
In early stages, patients complain of shoulder pain with both passive and active movement. This rapidly progresses to joint global stiffness actively and passively. In some cases, there is no glenohumeral motion at all, just scapulothoracic motion. In other cases, loss of ROM is only at the shoulder end ranges.
Examination does not reveal a specific point of tenderness. Occasionally, the long head of the biceps tendon is tender because its synovium is confluent with the synovium of the glenohumeral joint. Rotator cuff strength is usually normal in the preserved range of motion. Both passive and active ROM of the shoulder is restricted with loss of external ROM with the arm at the patient’s side a hallmark of this condition. Loss of passive external ROM is the single most important finding on examination and helps to differentiate the diagnosis from rotator cuff pathology, since the latter does not result in loss of passive ROM.12 An additional physical examination sign with good sensitivity is the shrug sign.13 The shrug sign is classically described as the inability to lift the arm to 90° abduction without elevating the whole scapula or shoulder girdle.
Patients may experience sleep disturbances due to pain or inability to sleep on their affected side. It might prevent them from performing activities of daily living (such as reaching for a wallet in the back pocket, combing the hair, fastening a bra in the back). It also might affect activities at work, particularly, those that require reaching. Furthermore, it might affect recreational activities that feature significant use of the upper extremity such as swimming, throwing a ball, etc.12 Significant correlation between functional disability related to lack of shoulder ROM & quality of life, as well. 14
Usually no lab studies are needed unless there is a need evaluate for an underlying condition such as diabetes mellitus, thyroid dysfunction, rheumatological disorders, etc.
Although radiographs are typically normal, they are important to exclude other causes. Neither magnetic resonance imaging (MRI) nor magnetic resonance arthrography is used as a primary diagnostic tool; however, recognition of AC on these modalities may be helpful. Thickening of the joint capsule and diminished filling of the axillary pouch are useful diagnostic criteria on magnetic resonance arthrography.15-16 Emig et al found thickness of the capsule >4 mm and of the synovium adjacent to the axillary recess to be highly specific for AC.17
Supplemental assessment tools
In order to evaluate the impairment, goniometry measurement in the different planes can be used. Alternatively, the patient can be asked to actively test the limits of motion. If loss of motion is observed, the physician may assist passively, with scapular stabilization to ensure an accurate measurement of movement. The most widely accepted method for measuring internal rotation is the Apley scratch test, usually expressed in terms of the highest vertebral level reached. Full ROM in any plane suggests another diagnosis. It is important to compare these maneuvers on the affected and unaffected sides to accurately assess deficits.4
Early predictions of outcomes
Some authors have suggested that AC is self-limited and does not need to be treated. Codman counseled his patients that their symptoms would gradually subside over time. 2 Miller et al recommended patience and found complete resolution of symptoms four years after onset in 50 patients treated with home exercise and heat.18 However, during this time a patient is often faced with significant functional deficits due to range of motion limitations. As appropriate interventions and therapy have been shown to significantly improve ROM and function, these measures should be strongly considered.
AC is more common in those with sedentary vocations than in manual laborers.1
It is important when examining the shoulder to expose the entire shoulder; not all clinicians do. This will rule out atrophy, winging scapulae and other asymmetries.
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Several treatments are available for AC depending on the phase of the disease. However, few of them have a high level of evidence to support them. Medical and rehabilitative treatment is a good start, but more invasive and surgical procedures are options if no response is attained. Medical treatments include non-steroidal anti-inflammatory drugs, physical therapy, and oral corticosteroids. Injection type treatments include glenohumeral joint injection of corticosteroids, hydrodilation, suprascapular nerve blocks (SSNB), manipulation under anesthesia, arthroscopic release, and open release.1,5 There has been some thought that intra-articular injection of visco-supplementation may improve outcomes with AC of the shoulder, but research has not shown additive benefits compared to conventional therapy. 19
At different disease stages
Physical therapist-supervised capsular stretching is the pillar of treatment and must always be present at all stages of disease When combined with other treatments, rehab therapy will result in better outcomes.4 The goals are to minimize capsular adhesions and restrictions of motion and to reduce pain and inflammation.4
- Treatment goals are to control inflammation and pain.
- Oral NSAIDs can be utilized as adjuvant to physical therapy.1,4
- Oral corticosteroids have shown a significant difference in terms of improvement compared to placebo at 3 to 6 weeks.1,4,19
- Physical therapy including therapeutic modalities in conjunction with corticosteroid injections has shown improved results. 1. Additionally, patients treated with corticosteroid injections received quicker action of pain relief compared to PO NSAIDS. 20
- Ultrasound guidance is recommended when performing a glenohumeral injection. Evidence reveals that accuracy varies from 89-100% using ultrasound compared to 10-100% performing this type of an injection with anatomic guidance.21
- A static progressive stretching program with physical therapy. 22
- A home exercise program, which includes education, activity modification, and progressive gentle range of motion exercises.
- After failed conservative treatments, more invasive treatments can be implemented such as intra-articular corticosteroid injection, 23 hydrodilatation or arthrographic distension,1,4,24-25 and suprascapular nerve block.1,19,26Additionally, some research has revealed that multiple injections 8 weeks apart might improve treatment in the short term (8 weeks) but data does not reveal any significantly greater improvement at 12 months. 27
- Suprascapular Nerve (SSN) Block combined with Physical Therapy. 24 The SSN provides approximately 70% of the capsular innervation and that blocking this may provide additional pain relief that allows for more aggressive progression of ROM in physical therapy.
- The optimal dosing, timing, and location of injection of corticosteroids is a challenging question. A recent systematic review revealed that evidence suggests that injections provide significant symptom relief for 2 to 24 weeks and that injections can be performed intra-articularly or into the subacromial space with positive effect for patients with adhesive capsulitis. Some evidence suggests that varying dosages (anywhere from 20 mg to 40 mg of triamcinolone as well as 40 mg of methylprednisolone) are all effective. Additionally, injections into the intra-articularl space and intra-bursal space were shown to be equally effective in decreasing pain and restoring shoulder function.28 There has been some concern that corticosteroids may result in chondrolysis, but recent data suggests this is not the case with respect to intra-articular corticosteroid injections. 29
- In addition, other treatment modalities that have shown beneficial effects and improved function in patients with adhesive capsulitis include joint mobilization combined with stretching exercises.30-31 Specifically, posterior glide exercises are shown to improve external rotation ROM. 30
- Same as in stage 1.
- Therapy and exercises will be expanded to joint glides, cane exercises, in order to keep or increase external and internal rotation, active exercises in the plane of the scapula.3
- Therapy will include aggressive stretching as the pillar; strengthening of the scapular muscles will be started as soon as the range of motion allows.
- Arthroscopic release provides better pain relief and restoration of function when compared with manipulation under anesthesia (MUA).1 Capsular release has supplanted MUA as the latter is also associated with complications including humeral fractures, subscapularis rupture, labral tears, and injuries of the biceps tendon.1,4,16,32
- Therapy same as stage 3. Arthroscopic release (has shown improved pain relief and restoration of function when compared with MUA).1,4,16,32
- Open release. Reserved for patients who have failed MUA and arthroscopic release.4
Coordination of care
A stage-based approach and treatment in conjunction with physical therapy is the best approach. Treatment failures will require an orthopedic surgeon’s input. Continuous communication with the patient, explaining of the course of the disease and treatment plan, along with a well-prepared and guided HEP, will provide better results.
Patient & family education
As mentioned previously, home therapy is one of the pillars of treatment. In order to have better results, the patient has to understand his role in the recovery process, as well as the importance of his active participation from the beginning of treatment.
Measurement of Treatment Outcomes including those that are impairment-based, activity participation-based and environmentally-based
The Shoulder Pain and Disability Index (SPADI) contains 13 items that assess two domains: a 5-item subscale that measures pain and an 8-item subscale that measures disability. It has been shown to be responsive to change over time in a variety of patient populations and is able to discriminate adequately between patients with improving and deteriorating conditions.33
The Constant-Murley Shoulder Outcome Score is one of the most commonly used outcome measures for assessing the treatment of shoulder disorders. It is the recommended scoring system of the European Society of Shoulder & Elbow Surgery (SECEC/ESSE) and has the benefit of including the pain score, functional assessment, range of motion and strength measures. 33
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Designing the appropriate treatment plan depends on recognition of the clinical stage. Because immobilization should be avoided, physical therapy and a guided home exercise program will be the pillars of treatment, in conjunction with a clear communication with the patient. Medical and rehabilitation treatments will be the first step, progressing to more invasive treatments, depending on the patient’s response.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
Targeting inflammatory cytokines in early stages (1 and 2) and decreasing fibrosis as well as enhancing capsular remodeling in late states (3 and 4) are the main goals of new agents.4 For better results with intra-articular corticosteroid injection, hydrodilatation, and SSNB in early stages, the use of ultrasound or radiographically guided procedures is recommended.1Manipulation under anesthesia was formerly the standard of care for recalcitrant cases, however, arthroscopy has shown good and sustained results.1,32 Additionally, the use of ultrasound to assess the thickness of the coracohumeral ligament (CHL) as a diagnostic imaging modality to determine CHL thickness in adhesive capsulitis of the shoulder has been shown to be effective in diagnosing AC given that a thickened CHL is suggestive of adhesive capsulitis.34
Newer unique interventions with positive outcomes include:
- Extracorporeal Shockwave Therapy.35 Chen et al. believe that ESWT stimulates soft-tissue healing, increases blood flow to the treated site, and induces an inflammatory-mediated healing process.
- Pulsed radiorefrequency stimulation lesioning of the suprascapular nerve for pain control.36
- Whole Body Cryotherapy. Whole-body cryotherapy (WBC) is administered for two to three minutes on the surface of the body in minimal clothing at −110°C to −140°C. Ma et al. hypothesized that WBC could have a positive effect on the rate of post-injury recovery after conservative AC treatment. Their study suggested that WBC provided a significant improvement in all outcome measures and ROM measures from pre to post treatment. 37
- Capsule-preserving intra-articular hydraulic distension with hypertonic saline, which has been show to decrease tissue edema, has been shown to be more effective than using normal saline when measuring shoulder passive ROM as well as assessing pain scores. 38
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
There is a need of high-level evidence studies on different treatment alternatives for each stage of the disease. New medications able to control or modify the course of the disease, such as non-steroidal anti-inflammatory drugs (NSAIDS)39 in early stages are needed. Further, more information on the number, type, and timing of office-based injections and procedures to best optimize participation in therapy and functional outcomes is needed, as well as which stages these treatments may be more or less effective
- Nevasier A, Hannafin J. Adhesive capsulitis: A review of current treatment. Am J Sports Med. 2010;38:2346.
- Duplay E. De la periarthrite scapulo-humérale et des raideurs de l`épaule qui en sont la conséquence. Arch Gen Med. 1872;20:513–542.
- Codman EA. The shoulder: Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston, MA: T Todd Company; 1934.
- Ewald A. Adhesive capsulitis: A review. Am Fam Physician. 2011;Feb 15;83(4):417-422.
- Binder AI, Bulgen DY, Hazleman BL, et al. Frozen shoulder: a long-term prospective study. Ann Rheum Dis.1984;43(3):361-364.
- Hsu JE, Anakwenze OA, et al. Current review of adhesive capsulitis. J Shoulder Elbow Surg. 2011;Apr;20(3):502-14.
- Uppal HS, Evans JP, Smith C. Frozen shoulder: A systematic review of therapeutic options. World J Orthop. 2015 Mar 18;6(2):263-8.
- Manske RC, Prohaska D. Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med. 2008 Dec; 1(3-4):180-9.
- Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg. 2008;17(2):231-236.
- Hannafin JA, Chiaia TA. Adhesive capsulitis: a treatment approach. Clin Orthop Relat Res. 2000;372:95-109.
- Yoo JC, Ahn JH, Lee YS, Koh KH. Magnetic resonance arthrographic findings of presumed stage-2 adhesive capsulitis: focus on combined rotator cuff pathology. 2009;32(1):22.
- Frontera W, Silver J. Essentials of Physical Medicine and Rehabilitation. Hanley & Belfus; 1st Edition 92001. 62-66.
- Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012 Nov;46(14):964-78.
- Fernandes M. Correlation between functional disability and quality of life in patients with adhesive capsulitis. Acta Ortop Bras. 2015 Mar-Apr;23(2):81-4.
- Lee MH, Ahn JM, Muhle C, et al: Adhesive capsulitis of the shoulder: Diagnosis using magnetic resonance arthrography, with arthroscopic findings as the standard. J Comput Assist Tomogr. 2003;27(6):901-906.
- Sofka CM, Ciavarra GA, Hannafin JA, et al: Magnetic resonance imaging of adhesive capsulitis: Correlation with clinical staging. 2008;4(2):164-169.
- Emig EW, Schweitzer ME, Karasick D, et al: Adhesive capsulitis of the shoulder: MR diagnosis. Am J Roentgenol. 1995;164(6):1457-1459.
- Miller MD, Wirth MA, Rockwood CA: Thawing the frozen shoulder: The patient. 1996;19(10):849-853.
- Lee LC, Lieu FK, Lee HL, Tung TH. Effectiveness of hyaluronic acid administration in treating adhesive capsulitis of the shoulder: a systematic review of randomized controlled trials. Biomed Res Int. 2015;2015:314120.
- Faveiee MM, Huisstede BM, Koes BW. Frozen shoulder: the effectiveness of conservative and surgical interventions-systematic review. Br J Sports Med. 2011Jan;45(1):49-56.
- Ranalletta M, Rossi LA, Bongiovanni SL, Tanoira I, Elizondo CM, Maignon GD. Corticosteroid injections accelerate pain relief and recovery of function compared with oral NSAIDs in patients with adhesive capsulitis: A randomized controlled trial. Am J Sports Med. 2016 Feb;44(2):474-81.
- Finnoff JT, Hall MM, Adams E, Berkoff D, Concoff AL, Dexter W, Smith J. American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine. Br J Sports Med. 2015 Feb;49(3):145-50. doi: 10.1136/bjsports-2014-094219. Epub 2014 Oct 20.
- Ibrahim MI, Johnson AJ, Pivec R, Issa K, Naziri Q, Kapadia BH, Mont MA. Treatment of adhesive capsulitis of the shoulder with a static progressive stretch device: a prospective, randomized study. J Long Term Eff Med Implants. 2012;22(4):281-91.
- Shin SJ, Lee SY. Efficacies of corticosteroid injection at different sites of the shoulder for the treatment of adhesive capsulitis. J Shoulder Elbow Surg. 2013 Apr;22(4):521-7.
- Buchbinder R, Green S, Forbes A, Hall S, Lawler G. Arthrographic joint distension with saline and steroid improves function and reduces pain in patients with painful stiff shoulder: results of a randomised, double blind, placebo controlled trial. Ann Rheum Dis. 2004 Mar; 63(3):302-9.
- Klç Z, Filiz MB, Çakr T, Toraman NF. Addition of suprascapular nerve block to a physical therapy program produces an extra benefit to adhesive capsulitis: A randomized controlled trial. Am J Phys Med Rehabil. 2015 Oct;94(10 Suppl 1):912-20.
- Sharma SP, Bærheim A, Moe-Nilssen R, Kvåle A. Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care. BMC Musculoskelet Disord. 2016 May 26;17(1):232.
- Xiao, Ryan C.; Walley, Kempland C.; DeAngelis, Joseph P., Ramappa, Arun J. Corticosteroid injections for adhesive capsulitis: A review. Clinical Journal of Sport Med. Post Author Corrections: July 18, 2016.
- Baumgarten KM, Helsper E. Does chondrolysis occur after corticosteroid-analgesic injections? An analysis of patients treated for adhesive capsulitis of the shoulder. J Shoulder Elbow Surg. 2016 Jun;25(6):890-7.
- Noten S, Meeus M, Stassijns G, Van Glabbeek F, Verborgt O, Struyf F. Efficacy of different types of mobilization techniques in patients with primary adhesive capsulitis of the shoulder: A systematic review. Arch Phys Med Rehabil. 2016 May;97(5):815-25.
- Celik D, Kaya Mutlu E. Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial. Clin Rehabil. 2015 Jul 30. pii: 0269215515597294. [Epub ahead of print]
- Barnes CP, Lam PH, Murrell GA. Short-term outcomes after arthroscopic capsular release for adhesive capsulitis. J Shoulder Elbow Surg. 2016 Mar 8. pii: S1058-2746(16)00008-2.
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- Homsi C, Bordalo-Rodrigues M, da Silva JJ, Stump XM. Ultrasound in adhesive capsulitis of the shoulder: is assessment of the coracohumeral ligament a valuable diagnostic tool? Skeletal Radiol. 2006 Sep;35(9):673-8.
- Chen CY, Hu CC, Weng PW, Huang YM, Chiang CJ, Chen CH, Tsuang YH, Yang RS, Sun JS, Cheng CK. Extracorporeal shockwave therapy improves short-term functional outcomes of shoulder adhesive capsulitis. J Shoulder Elbow Surg. 2014 Dec;23(12):1843-51.
- Wu YT, Ho CW, Chen YL, Li TY, Lee KC, Chen LC. Ultrasound-guided pulsed radiofrequency stimulation of the suprascapular nerve for adhesive capsulitis: a prospective, randomized, controlled trial. Anesth Analg. 2014 Sep;119(3):686-92.
- Ma SY, Je HD, Jeong JH, Kim HY, Kim HD. Effects of whole-body cryotherapy in the management of adhesive capsulitis of the shoulder. Arch Phys Med Rehabil. 2013 Jan;94(1):9-16.
- Lee JH, Kim SB, Lee KW, Lee SJ, Lee JU. Effect of Hypertonic Saline in Intra-Articular Hydraulic Distension for Adhesive Capsulitis. PMR. 2015 Jul;7(7):721-6.
- Dehghan A, Pishgooei N, Salami MA, Zarch SM, Nafisi-Moghadam R, Rahimpour S, Soleimani H, Owlia MB. Comparison between NSAID and intra-articular corticosteroid injection in frozen shoulder of diabetic patients; a randomized clinical trial. Exp Clin Endocrinol Diabetes. 2013 Feb;121(2):75-9.
Original Version of the Topic:
Erik Hoyer, MD, MA. Critical illness myopathy. Publication Date:2012/11/27.
Jason L. Zaremski, MD
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