Adhesive capsulitis

Background

Shoulder anatomy

Shoulder anatomy, anterior.

Shoulder anatomy, posterior.

• Also known as "frozen shoulder syndrome"
• Inflammation of glenohumeral joint → joint capsule fibrosis, shoulder restriction
• Must rule-out posterior shoulder dislocation
• Associated with:
  • Impingement Syndrome
  • Postmenopause
  • DM
  • Thyroid disease
  • Pulmonary neoplasm
  • Autoimmune

Clinical Features

• Hallmark is limited active and passive range of motion
• Shoulder pain
  • Diffuse, aching, poorly localized, accompanied by stiffness, worse at night
  • Not typically reproducible by palpation

Stage	Category	Timeline (months)	Findings
1	Acute	2-3	Acute synovial inflammation with limitation of shoulder movement due to pain
2	Freezing	3-9	Decreased shoulder motion due to capsular thickening/scarring; patient has chronic pain
3	Frozen	9-15	Less pain, but significantly decreased range of motion
4	Chronic	>15	Minimal pain, progressive improvement in shoulder range of motion

Evaluation

• Clinical diagnosis, consider X-ray to rule out fracture/dislocation

Differential Diagnosis

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

• Shoulder Dislocation
  • Anterior shoulder dislocation
  • Posterior shoulder dislocation
  • Inferior shoulder dislocation
• Clavicle fracture
• Humerus fracture
• Scapula fracture
• Acromioclavicular joint injury
• Glenohumeral instability
• Rotator cuff tear
• Biceps tendon rupture
• Triceps tendon rupture
• Septic joint

Nontraumatic/Chronic:

• Rotator cuff tear
• Impingement syndrome
• Calcific tendinitis
• Adhesive capsulitis
• Biceps tendinitis
• Subacromial bursitis
• Cervical radiculopathy

Refered pain & non-orthopedic causes:

• Referred pain from
  • Neck
  • Diaphragm (e.g. gallbladder disease)
• Brachial plexus injury
  • Rucksack paralysis
• Axillary artery thrombosis
• Thoracic outlet syndrome
• Subclavian steal syndrome
• Pancoast tumor
• Myocardial infarction
• Pneumonia
• Pulmonary embolism

Management

Shoulder MRI showing a thickened joint capsule, especially at the inferior recess, which can be a sign of adhesive capsulitis.

• Avoid immobilization
• Physical therapy
• Analgesia
  • NSAIDs, opioids
• Oral steroids
  • Provide significant short-term benefit in terms of relieving pain and improving ROM
• Intra-articular steroids (20-40mg triamcinolone)
  • Benefits last a few months, possibly up to 6 months
• Joint distention
  • Intra-articular distention with 25-40mL of saline + anesthetic is as effective as IA steroids

Disposition

• Discharge, refer to primary care/ortho for physical therapy

See Also

• Shoulder diagnoses