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.”
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.
The secondary disease typically follows trauma or injuries to the shoulder. Common injuries include rotator cuff tears, fractures, surgery, or immobilization.
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. Additionally, patients with diabetes typically have worse treatment outcomes depending on the duration of their diabetes.
The exact pathophysiology 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.
During arthroscopy, the following may be seen:
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:
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. Often, 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.
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.
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. There are limited studies that guide treatment management. The following are some viable treatment options:
Indications for Surgery
Contraindications for Surgery
Patient must enroll in a formal exercise program, irrespective of treatment.
Once a diagnosis of frozen shoulder is made, a physical rehabilitation clinician should be consulted.
Continue with exercise to prevent recurrence of symptoms.
Patients with frozen shoulder may present to the primary caregiver or nurse practitioner. However, it is important to know that 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. Several studies do show that in the long-term patients continue to have pain and or stiffness following conservative management.
Long-term disability has been reported in 10% to 20% of patients and persistence of symptoms in 30% to 60%.