Adhesive capsulitis(frozen shoulder)

Frozen Shoulder

—     
Any clinical condition with painful restriction of active and passive shoulder movements.

—  Example: Adhesive capsulitis, rotator cuff tear and sprain, tendinitis of rotator cuff, synovitis of the shoulder, etc.

 

Condition that causes frozen shoulder are mainly divided into two types for proper diagnosis and for proper treatment as the treatment of each is different.

 

a.      Painful shoulder: Any conditions, around the shoulder, that causes pain and limitation of shoulder movements are included in this group. 

b.      Adhesive capsulitis: Capsular adhesions form as a result of inflammation in the capsule and synovium.

 

A. Adhesive Capsulitis

—  Definition

—  Etiology

—  Clinical presentation

—  Provisional diagnosis

—  Differential diagnosis

—  Conformation test

—  Treatment

Definition

•      Capsular  adhesions form as a result of inflammation in the capsule and synovium .

•      Mostly due to idiopathetic  causes.

•      Codman introduce the term “frozen shoulder” to describe a patients who had a painful loss of shoulder motion with normal radiographic studies.

•      Neviaser named the condition “adhesive  capsulitis”  based on the radioraphic apperance with anthrography, which suggested “adhesion” of the capsule of the GH joint limiting overall joint space volume.

Etiology

•      Most common in female.

•      Occurs in between the age group of 40 to 60 years

•      Most commonly seen in following conditions

ü  Diabetes mellitus

ü  Cardiopulmonary diseases

ü  Mastectomy and other operation over the chest

ü  Cervical spondylosis

ü  Humerus fracture

ü  Parkinson’s diseases

ü  Stroke

ü  Presence of autoimmune diseases

Clinical presentation

•      Painful restriction of both active and passive GH joint motion in all plane (GLOBAL loss of GH joint motion)

•      It is most commonly associated with IDDM (In more than 50% of cases).

It has 3 clinical phases

1.      Freezing phase

2.      Frozen phase

3.      Thawing phase  

( Note: Even not performing full shoulder stretches in our daily activities may lead to capsular contracture and there by a stiff shoulder in a great majority of population.)

  

1.      Freezing phase

•      Also called painful or acute phase.

•      Aching pain in the shoulder.

•      More severe at night and during activities.

•      May be associated with discomfort that radiates down the arm.

•      As the time progress, movement decreases.

Most patients will position the arm in adduction and internal rotation.

This position represent the “neutral isometric position of relaxed tension  for the inflamed glenohumeral capsule, biceps, and rotator cuff”.

2. Frozen phase

•      Also called adhesive or stiffening phase.

•      Pain at rest usually diminished.

•      All shoulder motion are restricted in all planes.

•      ADL are severely restricted.

•      Patients complain about inability to reach their back pocket, comb the hair, or wash opposite shoulder.

•      While performing these activities patient has sharp, acute discomfort and movement is restrict due to capsular tighten.

•      Pain at night is also a common complaint. 

3. Thawing phase

•      Also called resolution phase

•      Stage is characterized by a slow recovery of motion.

•      Physical therapy, closed manipulation or surgical release may accelerate recovery.   

Provisional diagnosis

—  There are no such particular special tests for it.

—  It may be suggested by history and physical examination

•      In history

ü  Onset of pain and duration 

ü  Duration of symptoms

ü  Description of any trauma

ü  Any associated medical conditions

•      Physical examination: vary depending on the stage at which the patient presents for treatment.

ü  In general, GLOBAL loss of active and passive movement is present.

ü  Loss of passive external rotation with the arm at the patient's side is a hallmark of this condition. (It is the single important finding on physical examination.)

Differential diagnosis

1. Osteoarthritis (OA)

•      Both may have limited abduction and external rotation AROM but with OA, PROM will not be limited.

•      Also, OA will have the most limitations with flexion while this is the motion that is least affected in adhesive capsulitis.

•      Radiography have been used to rule out pathology of osseous structures.

2. Bursitis

—  Bursitis presents very similarly to adhesive capsulitis, especially compared to the early phases of frozen shoulder.

—      Patients with bursitis will present with a non-traumatic onset of severe     pain with most motions being painful.

—  A main difference will be the amount of PROM achieved with adhesive capsulitis being extremely limited and painful but in bursitis PROM is not affected too much.

3. Parsonage-Turner Syndrome (PTS)

•      PTS occurs due to inflammation of the brachial plexus

•      Patients will present without a history of trauma and with painful restrictions of all motions.

•      But the pain with PTS usually subsides much quicker than with adhesive capsulitis, and patients eventually display neurological problems (atrophy of muscles or weakness).

4. Rotator Cuff (RC) Pathologies

•      Loss of passive external rotation is not present in case of RC pathologies.

•      Adhesive capsulitis presents with restrictions in the capsular pattern while it is not present in RC.

•      MRI and ultrasonography can be used to identify soft tissue abnormalities of the soft tissue and labrum.

5. Posterior shoulder dislocation

•      It also lack external rotation and abduction but axillary lateral X-ray shows a dislocated humeral head.

Conformation tests

—  Loss of passive external rotation with Global loss of active and passive motion.

—  The diagnosis of adhesive capsulitis are conformed when radiographic studies are normal.

Treatments

—  Even though it is believed to be a “self limiting” process, it can severely make a person disable for month to year so proper diagnosis and treatment is necessary.

1.      Analgesics (oral or peri-articular injection of hydrocortisone) is given to reduce pain and inflammation.

2.      Physiotherapy with shoulder mobilization

3.      Arthroscopic capsular release