Adhesive Capsulitis (Frozen Shoulder)

Adhesive Capsulitis (Frozen Shoulder) web based movie

Overview

The shoulder is a “ball & socket” joint. The upper part of the arm bone (humerus) forms a ball shape that sits in a small cup, or socket (called the “glenoid”), on the side of the shoulder blade. The shoulder joint is enclosed by soft tissue that surrounds the shoulder like a plastic bag. This soft tissue bag is called the “joint capsule.” Adhesive capsulitis, also known as “frozen shoulder” occurs when the joint capsule becomes inflamed and ultimately thickens causing painful and restricted shoulder motion.

The cause of adhesive capsulitis is not fully understood. Adhesive capsulitis is much more common in patients with diabetes. Other risk factors include thyroid dysfunction, Parkinson’s disease and cardiac disease or surgery. it most commonly affects women between ages of 40-60 years old. In cases where the condition develops in isolation it is referred to as “primary” adhesive capsulitis. Patients may also develop adhesive capsulitis as a result of a traumatic injury (such as a fracture), shoulder surgery, or avoidance of certain painful shoulder positions due to other shoulder conditions such as impingement syndrome or rotator cuff disorders. These cases that result from other co-existing shoulder problems are termed “secondary” adhesive capsulitis.

Symptoms

Symptoms of adhesive capsulitis include pain and significant stiffness in the shoulder with limitation in range of motion. The disease process normally goes through three stages. Phase 1 is the inflammation phase where patients experience the onset of severe shoulder pain with no obvious cause. As the pain worsens, the shoulder begins to develop stiffness and limitations in range of motion. Phase 2 is the freezing phase where pain typically subsides but limitations in shoulder motion persist or worsen. Phase 3 is the thawing phase in which the range of motion gradually improves back to normal.

Adhesive capsulitis is generally a condition that is termed “self-limited,” meaning that the condition will ultimately run its course with a decrease in pain and improvement in range of motion over time. However, the process may take up to two years to fully resolve.

Diagnosis

Diagnosis of frozen shoulder is usually made by history of the patient’s symptoms and findings from a physical examination. X-rays are performed to exclude other reasons for shoulder pain and stiffness, such as arthritis. If there is confusion about the diagnosis, an MRI may be ordered; this will typically show a thickened joint capsule and no other abnormalities in isolated and “primary” adhesive capsulitis.

Treatment

Due to the self-limiting nature of this condition, treatment of adhesive capsulitis is usually non-operative initially and geared toward accelerating the course of the disease process and limiting the period of shoulder disability. In the painful phase, a cortisone injection into the shoulder joint can be very effective at decreasing inflammation, pain, and limiting thickening of the joint capsule and scarring in the joint. Typically a course of physical therapy is initiated as soon as pain subsides, combined with a two- to three-times daily home stretching program to aggressively work on improving range of motion. Heat is helpful to “loosen” the shoulder just prior to stretching and patients often perform the stretching exercises in the shower. Icing is helpful after stretching to limit any rebound inflammation. The patient is seen at regular intervals to measure shoulder motion and provide feedback and advice on the progress of therapy. It often takes several weeks or months to fully resolve the condition.

Surgical treatment is recommended for patients who fail to regain full motion or who “plateau” and are unable to progress with range of motion improvement after several months of non-operative treatment. The surgery involves two components. First, a manipulation of the shoulder is done with the patient asleep and under anesthesia to break up residual thickening and scaring in the joint capsule. Next, an arthroscopic procedure, called a “capsular release,” is performed to look inside the shoulder joint and directly cut and remove any scarred areas of the joint capsule. Aggressive physical therapy and motion exercises are then begun immediately after the procedure to prevent re-scarring of the joint capsule.

Additional Information

For more information, visit http://orthoinfo.aaos.org/topic.cfm?topic=A00071.