adhesive capsulitis (frozen shoulder)
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Introduction
Pain & restricted movement of the shoulder, generally in the absence of intrinsic joint disease.
Etiology
- may follow bursitis or tendonitis of the shoulder (rotator cuff tendonitis)
- may be associated with systemic disorders
- prolonged immobility of the arm
- arthritis[5]
- reflex sympathetic dystrophy
- trauma
- hemarthrosis
Epidemiology
- most common in women > 50 years[1][4] > 40 years[11]
- equally common in men & women[3]
- occurs more commonly in diabetics (30%)
- associated with diabetic retinopathy, but not neuropathy or proteinuria
Pathology
- the capsule of the shoulder is thickened
- mild chronic inflammatory infiltrate may be present
- fibrosis may be present, esp involving the coracohumeral ligament &/or glenohumeral capsule[11]
Clinical manifestations
- pain & decreased range of motion in all directions
- both active & passive movement are restricted*, especially external rotation & abduction
- pain & stiffness generally develop gradually over a period of months to 1 year, but may progress more rapidly
- pain is located diffusely about anterior & posterior regions of the shoulder joint
- atraumatic progressive pain in the anterolateral aspect of the shoulder
- pain is deep & aching & is often worse at night & in cold weather
- may be early painful (freezing phase) lasting weeks to months followed by adhesive stiffening phase lasting 4-12 months[6]
- patients may be unable to recall trauma or injury
- pain may interfere with sleep, especially when patient rolls onto shoulder
- strength may be normal
- impingement sign may be mildly positive
- the shoulder is tender to palpation at the insertion of the deltoid tendon[2]
* contrast to rotator cuff tendonitis where mostly active range of motion is impaired
Radiology
- X-ray of shoulder shows osteopenia, otherwise normal
- arthrogram: < 15 mL of contrast can be injected into the joint
- magnetic resonance imaging diagnostic
- needed only to evaluate associated shoulder conditions
Differential diagnosis
- acromioclavicular arthritis
- does not present with severe stiffness & extremely poor range of motion
- pain with palpation of the acromioclavicular joint
- Milwaukee shoulder syndrome
- affects older women
- may be precipitated by overuse or trauma
- radiographic features:
- destruction of subchondral bone
- soft tissue swelling
- intra-articular effusion is usually present
- subacromial bursitis
- does not present with severe stiffness & extremely poor range of motion.
- commonly associated with impingement syndrome caused by overhead activities
- pain on palpation of the anterolateral aspect of the shoulder
- pain on resisted abduction beyond 75 degrees,
Management
- early mobilization of an arm after injury to a shoulder may prevent development of adhesive capsulitis
- gentle physical therapy with ultrasound
- as effective as more invasive intervention[7]
- glucocorticoid injection into glenohumeral joint
- may provide some relief of symptoms[2]
- associated with better outcomes[8]
- non-steroidal anti-inflammatory drugs (NSAIDs) be be of some benefit
- slow, but forceful injection of contrast into the joint may lyse adhesions & stretch the capsule, resulting in an improvement of shoulder movement
- manipulation under anesthesia may help some patients[7]
- refractory cases may require arthroscopic surgical release
- failure of 9-12-month course of nonoperative therapy[11]
- prognosis:
- most patients improve spontaneously in 12-18 months
- some may have permanent restriction of movement
- once the disease is established, therapy may have little impact on its natural course
More general terms
Additional terms
References
- ↑ 1.0 1.1 Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1709
- ↑ 2.0 2.1 2.2 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ 3.0 3.1 Clyman B, in: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ 4.0 4.1 Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1961
- ↑ 5.0 5.1 Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
- ↑ 6.0 6.1 Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
- ↑ 7.0 7.1 7.2 Rangan A, Brealey SD, Keding A et al. Management of adults with primary frozen shoulder in secondary care (UK FROST): A multicentre, pragmatic, three-arm, superiority randomised clinical trial. Lancet 2020 Oct 3; 396:977 PMID: https://pubmed.ncbi.nlm.nih.gov/33010843 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31965-6/fulltext
- ↑ 8.0 8.1 8.2 Challoumas D, Biddle M, McLean M et al Comparison of Treatments for Frozen Shoulder. A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(12):e2029581. Dec 16 PMID: https://pubmed.ncbi.nlm.nih.gov/33326025 PMCID: PMC7745103 Free PMC articl https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774247
- ↑ Ramirez J Adhesive Capsulitis: Diagnosis and Management Am Fam Physician. 2019 Mar 1;99(5):297-300. PMID: https://pubmed.ncbi.nlm.nih.gov/30811157 Free article
- ↑ Le HV, Lee SJ, Nazarian A, Rodriguez EK. Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments. Shoulder Elbow. 2017 Apr;9(2):75-84. PMID: https://pubmed.ncbi.nlm.nih.gov/28405218 PMCID: PMC5384535 Free PMC article
- ↑ 11.0 11.1 11.2 11.3 Redler LH, Dennis ER. Treatment of adhesive capsulitis of the shoulder. J Am Acad Orthop Surg. 2019;27:e544-e554. PMID: https://pubmed.ncbi.nlm.nih.gov/30632986
- ↑ Pandey V, Madi S. Clinical guidelines in the management of frozen shoulder: an update! Indian J Orthop. 2021;55:299-309. PMID: https://pubmed.ncbi.nlm.nih.gov/33912325