Adhesive CapsulitisMohamed Ahmed Hefny, MD.

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Definition

• Primary idiopathic, progressive, painful but self-limited restriction of active and passive range of motion.

• Insidious onset and progresses through several stages, usually during the course of 1 to 2 years.

1. Painful phase2. Freezing or adhesive phase, and 3. Thawing or resolution phase

• Occurs in 2% to 5% of the general population and accountsfor approximately 6% of office visits to shoulder specialists

• Preferentially affects women after the age of 50• Involves the non-dominant shoulder, and develops in the

opposite shoulder in 20% to 30% of cases. • The primary etiology is unknown, but it is associated with

numerous secondary causes, including immobilization, diabetes, hypothyroidism, autoimmune disease, and treatment of breast cancer

• Pathologic process related to it involves structures both intrinsic to the glenohumeral joint and surrounding

• It is not clear, stimulation of synovitis leads to fibrosis due to the activation of various cytokines, including growth factors such as transforming growth factor-β.

• Pathologic findings ultimately depend on its stage when it is assessed.

1. Painful phase, is characterized by synovitis that progresses to capsular thickening (particularly in the anterior and inferior portions of the capsule) with an associated reduction in synovial fluid.

2. Adhesive phase, fibrosis of the capsule is more pronounced, and thickening of the rotator cuff tendons is common.

3. Resolution phase, the glenohumeral joint space becomes contracted and often obliterated. Pathologic change is more consistent with chronic inflammation with resolution of joint space loss during the final stage.

Symptoms

Will depend on the stage of adhesive capsulitis. • In stage 1 (symptoms lasting < 3 months), 1. Gradual onset of progressive pain2. Worse during the night3. Exacerbated by overhead activities 4. gradual loss of motion• In stage 2 (lasting 9-12 months)1. progressive increase in pain 2. ROM reduction and decreased use of the affected

shoulder • Stage 3, the “thawing stage,” 1. Gradual decrease in pain and increase in the pain-free

ROM 2. Some individuals will return to normal, but not all

Physical Examination

• During the painful and adhesive stages there is a: 1. Measurable reduction in both passive and active shoulder

ROM2. Motion is painful, particularly at the extremes of external

rotation and abduction• This pattern of motion loss is consistent with a capsular

pattern of passive range of motion loss, which demonstrates a greater limitation in external rotation and abduction followed by an increasing loss of flexion.

• These signs are similar to those found in osteoarthritis of the glenohumeral joint, in which there is a similar loss of motion with shoulder pain.

• However, this presentation is in contrast to findings seen in rotator cuff tears, in which active range of motion is restricted but passive range of motion may approximate normal values.

• A reduced glenohumeral glide is often noted with adhesive capsulitis, especially with inferior translation.

• The relationship of glenohumeral joint movements independent of scapulothoracic motion should also be noted.

• Last, the shoulder is often painful to palpation around the rotator cuff tendons distally. As symptoms start to improve and the patient enters the resolution stage, there is a reversal of the loss of motion, with internal rotation being the last to improve.

• Neurologic evaluation findings are usually normal in adhesive capsulitis, although manual muscle testing may detect weakness secondary to pain or disuse.

• However, concomitant rotator cuff involvement is common and could explain true weakness if it is noted on physical examination.

• The combination of myotomal weakness, altered dermatomal sensation, reflex asymmetry, and positive findings with cervical spine provocative testing is more suggestive of a neurologic cause of shoulder pain.

Functional Limitations

• Patients often experience sleep disruption as a result of pain or inability to sleep on the affected side.

• Inability to perform activities of daily living (e.g., fastening a bra in the back, putting on a belt, reaching for a wallet in the back pocket, reaching for a seat belt, combing the hair) is common.

• Work activities may be limited, particularly those that involve overhead activities (e.g., filing above waist level, stocking shelves, lifting boards or other items).

• Recreational activities (e.g., difficulty serving or throwing a ball, inability to do the crawl stroke in swimming) are also affected.

Diagnostic Studies

• AC is associated with other comorbidities in addition to common neoplastic processes, routine blood work and radiographs should be obtained to rule out secondary causes

• Radiographs in patients with AC are generally normal. In advanced stages, joint space narrowing may be noted on arthrograms as there is a reduced volume of injectable contrast material into the joint.

• MRI may also prove to be a useful diagnostic tool; studies have confirmed findings seen at arthroscopy, including thickening of the coracohumeral ligament and obliteration of the subcoracoid space.

• US allows a dynamic view of the shoulder region with a sensitivity of 91%, a specificity of 100%, and an accuracy of 92% for detection of AC.

Arthrogram of shoulder with advanced adhesive capsulitis with a contracted joint space. Note the absence of the axillaryrecess and the reduced amount of contrast material injected.

Treatment

Initial• Goals depend on the stage of AC• General goals are to: 1. Decrease pain and inflammation2. Increasing the shoulder ROM in all planes.

• Pain and inflammation should be managed with ice, medications, and activity modifications. NASID’s is generally advocated, although it has not been clearly shown to have an impact on the resolution of pain.

• A short trial of oral steroids has been shown to more rapidly decrease pain comparedwith placebo, but the benefits are not sustained during long-term follow-up.

• Intra-articular injection of corticosteroids (± Lidocaine) has been shown to be helpful during the early stages of AC compared with placebo, but it does not change long-term outcomes.

Rehabilitation

• The standard of treatment mainly involves physical therapy and home exercises to restore range of motion for the treatment of adhesive capsulitis.

• The clinician will measure the need for physical therapy versus a home exercise program and rate of progression of therapy as AC can take months to years to resolve.

1. Factors affecting the setting and pace of rehabilitation include 2. Severity of the patient’s symptoms3. Physical examination findings4. Ability to perform the exercises appropriately, and 5. Compliance with a home exercise program• Initially, pendulum exercises, overhead stretches, and crossed

adduction of the affected arm should be taught to patients while they are in the physician’s office once AC is suspected to prevent further loss of function

• Others will choose physical therapy early to manage pain, to improve the pain-free ROM, and to prevent further contraction of the joint capsule.

• As the patient progresses with physical therapy, a more detailed home exercise program should be implemented on the basis of the patient’s understanding of and compliance with the exercises.

• If the patient shows continued progress with less pain and improved ROM, exercises should be graduated to strengthening of rotator cuff muscles and periscapular stabilizers.

• Once symptoms resolve, patients should be encouraged to continue the home exercise program to maintain range of motion and to prevent recurrence of AC.

Procedures

• In the treatment of AC, procedures are often performed in conjunction with physical therapy sessions and primarily involve pain-alleviating modalities.

• These procedures may include intra-articular joint injection, suprascapular nerve blocks, and joint capsule hydrodilation

• Intra-articular injections can be used to break pain cycles. • Several small studies using suprascapular nerve blocks

have also reported them to be helpful in breaking pain cycles associated with AC.

• Hydrodilation involves glenohumeral injections with saline or lidocaine to lyse adhesions and to distend the capsule. Unfortunately, more studies are needed to fully understand its efficacy.

Surgery

• The decision to perform surgery is based on failure of conservative management or an unacceptable QOL.

• Manipulation under anesthesia followed by immediate physical therapy focusing on improvement of ROM of the glenohumeral joint can be helpful for refractory cases.

• Arthroscopic lysis of adhesions may be an effective option if all else has failed

Potential Disease Complications

• Pain is usually transient but can persist for months as the condition runs its clinical course.

• The loss of ROM seen in AC is usually regained, but it has been reported that as many as 15% of patients develop permanent loss of full ROM.

• ROM loss is often not associated with functional deficits

Potential Treatment Complications

• Treatment complications from conservative management are rare but can include side effects associated with NSAID’s and analgesic medications; these include GI bleeds, gastritis, toxic hepatitis, and renal failure.

• Caution should be used in the treatment of patients with CHF and HTN because of fluid retention associated with the use of NSAID’s.

• Patients undergoing physical therapy could experience significant pain from too aggressive therapeutic exercises or manipulation.

• In patients undergoing suprascapular nerve blocks, care must be taken to prevent intraneural and intravascular injections.

• A common surgical complication that can occur is a humeral fracture during manipulations under anesthesia.

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