History

Fact Explanation
Shoulder pain Adhesive capsulitis has been described as having three sequential phases: painful stage, frozen stage and thawing stage. A limited range of motion can occur at any point of the natural history of the disease. Pain increases progressively and is caused by inflammation of the joint capsule. The pain is diffuse and constant but can gets worse at night especially when lying on the affected side. [1,2,3] During the frozen stage, pain is static, shoulder movements are restricted. Later, during the thawing stage pain becomes minimal and there is an increase in the range of movement. [1,2]
Reduced range of movements (ROM) in the shoulder Active and passive ROM becomes restricted. This occurs due to an acute synovitis of the glenohumeral joint.[1] There is a typical pattern of restricted movements: capsular pattern of the shoulder - external rotation and abduction are greatly affected, in addition internal rotation is affected in severe cases. [3] Prolonged immobilization due to pain causes: decreased collagen length, infiltration of fibrous and fatty tissue and ligament atrophy. These fibrous contractures of the rotator interval and coracohumeral ligament of the shoulder joint are histologically composed of mature type III collagen matrix and is highly cellular with fibroblasts and contractile myofibroblasts. Pathological findings are similar to those found in Dupuytren's contracture. [1,2]
Possibility of co-existing Diabetes Mellitus, chronic rotator cuff injury, history of a fracture involving the shoulder joint. Adhesive capsulitis affects 20% of those with diabetes and is the most disabling musculoskeletal manifestation of diabetes. These conditions occur due to poor circulation leading to abnormal collagen repair and degenerative changes. [4,5]
Sleep disturbances Sleep disturbance is due to pain caused by rolling on the affected shoulder while sleeping. In addition painful stiffening of the joint capsule may cause pain over time. Sleeping on the back or on the opposite shoulder may be preventive. [6]
References
  1. BUNKER,T.D. Frozen shoulder: unravelling the enigma. Ann R Coll Surg Engl [Online], May 1997, 79(3), 210–213. [viewed 16 March 2014]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502880/
  2. ANTON,H.A. Frozen shoulder. Can Fam Physician [Online], 1993,39,1772– 8. [viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379805/
  3. MANSKE,R.C, D.PROHASKA. Diagnosis and management of adhesive capsulitis.Curr Rev Musculoskelet Med [Online], Dec 2008, 1(3-4), 180–189. [viewed 16 March 2014]. Available from: doi: 10.1007/s12178-008-9031-6
  4. BUNKER,T.D, P.P.ANTHONY. The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br [Online], 1995 Sep,77(5),677–683. [viewed 16 March 2014]. Available from: http://www.bjj.boneandjoint.org.uk/content/77-B/5/677.long
  5. KAY,N.R, D.N.SLATER. Fibromatoses and diabetes mellitus. Lancet.[Online] 1981 Aug 8,2(8241),303–303. [viewed 16 March 2014]. Available from:http://www.sciencedirect.com/science/article/pii/S0140673681905444
  6. VERMEULEN,H.M. et al. End-Range Mobilization Techniques in Adhesive Capsulitis of the Shoulder Joint: A Multiple-Subject Case Report. Physical Therapy [online].December 2000,80(12),1204-1213. [viewed 16 March 2014]. Available from: http://www.physther.org/content/80/12/1204.full.pdf+html

Examination

Fact Explanation
Shoulder tenderness [1,2] Diffuse shoulder tenderness due to capsular inflammation specially during the painful stage.
Reduced range of movements [1,2] Reduced range of movements can be demonstrated during any stage of adhesive capsulitis. However it is marked during the painful and freezing stages when movements are restricted due to inflammatory pain and mechanical constraints. During the thawing stage,there is a progressive improvement in pain and movement. Movement is limited in all planes and in both active and passive movement. Most affected part of the capsule is identified by: external rotation with the arm adducted this tests for contracture of the antero-superior portion of the capsule; external rotation with arm abducted this tests for contracture of the antero-inferior portion of the capsule Internal rotation. [3]
Coracoid test The test is positive when digital pressure on the coracoid area generates intensive pain in comparison to the other shoulder. [4]
Apleys scratch test Patient is asked to place a hand behind their back and reach as high up along the spine as possible. Note that they should be able to reach the lower border of the scapula.[5]
Crepitations Felt with attempts to abduct the arm beyond 60 degrees. Crepitations are created by grinding of bone against bone. [6]
References
  1. WHITE,R.H et al. Shoulder Pain. West J Med[Online], Oct 1982, 137(4), 340–345. [viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989032/pdf/264_2010_Article_1038.pdf
  2. MANSKE,R.C, D.PROHASKA. Diagnosis and management of adhesive capsulitis.Curr Rev Musculoskelet Med[Online], Dec 2008, 1(3-4), 180–189. [viewed 16 March 2014]. Available from: doi: 10.1007/s12178-008-9031-6
  3. KIRCHHOFF,C, A.B.IMHOFF. Posterosuperior and anterosuperior impingement of the shoulder in overhead athletes—evolving concepts. Int Orthop[Online], Oct 2010, 34(7), 1049–1058.[viewed 16 March 2014]. Available from: doi: 10.1007/s00264-010-1038-0
  4. CARBONE, S. GUMINA,R. POSTACCHINI,R. Coracoid pain test: a new clinical sign of shoulder adhesive capsulitis,Int Orthop[Online]. Mar 2010, 34(3), 385–388.[viewed 16 March 2014]. Available from: doi: 10.1007/s00264-009-0791-4
  5. WOODWORD, T.W. T.M. BEST.The Painful Shoulder: Part I. Clinical Evaluation. Am Fam Physician[Online], 2000 May 15,61(10),3079-3088. [viewed 16 March 2014]. Available from: http://www.aafp.org/afp/2000/0515/p3079.html
  6. ANTON,H.A. Frozen shoulder. Can Fam Physician[Online], 1993,39,1772– 8. [viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379805/

Differential Diagnoses

Fact Explanation
Acromioclavicular arthropathy Shoulder pain localizes over the acromioclavicular joint. There is a history of repetitive overuse such as weight lifting. Positive cross-arm adduction and compression testing; glenohumeral range of motion is preserved. [1,2]
Autoimmune disease (SLE, rheumatoid arthritis) Multi system involvement. Multiple joints are involved. [1,3]
Biceps tendinopathy Pain localizes anteriorly.Tenderness over long head of the biceps tendon.Yergason test is positive. [4,5]
Cervical disk degeneration Pain localizes posteriorly along with hand numbness and weakness. Limited range of motion in neck,intrinsic hand weakness and impaired light touch are associated.[1,2]
Glenohumeral osteoarthritis History of shoulder trauma or surgery.Usually in the older age.Shoulder girdle atrophy may be present. [1,2,3]
Rotator cuff tendinopathy or tear Pain often localizes anteriorly or laterally.Passive range of motion is preserved.Usually a history of repetitive overuse is present. [1,2]
Subacromial and subdeltoid bursitis Passive range of motion is preserved. Possible history of repetitive overuse is present. [1,2]
References
  1. WHITE,R.H et al. Shoulder Pain. West J Med[Online], Oct 1982, 137(4), 340–345. [viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989032/pdf/264_2010_Article_1038.pdf
  2. HE'ERI,G.B. et al. Ruptures of the rotator cuff. Can Med Assoc J[Online], 1980 Oct 4, 123,620-627. [viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705609/
  3. KESSEL,L, M.WATSON.The painful arc syndrome-Clinical classification as a guide to management. J Bone Joint Surg [Br][Online], 1977 May, 59,166-172. [viewed 16 March 2014]. Available from: http://www.bjj.boneandjoint.org.uk/content/59-B/2/166.long
  4. ANTHONY,E. Adhesive Capsulitis: A Review.Am Fam Physician[Online], 2011 Feb 15,83(4),417-422. [viewed 16 March 2014]. Available from: http://www.aafp.org/afp/2011/0215/p417.
  5. CHURGAY,M.D, A.CATHERINE Diagnosis and Treatment of Biceps Tendinitis and Tendinosis, Am Fam Physician[Online].2009,80(5),470-476.[viewed 5 April 2014]. Available from: http://www.aafp.org/afp/2009/0901/p470.html

Investigations - for Diagnosis

Fact Explanation
X-ray shoulder Adhesive capsulitis is primarily a clinical diagnosis However, X Ray shoulder may be requested if the diagnosis is in doubt. It frequently shows osteopenia of the humeral head. Important in excluding other possible diagnosis of loss of ROM that include osteoarthritis, chronic anterior or posterior dislocation.[1,2]
Arthrography Usually diagnostic.It will show contracted joint capsule, loss of bursal out pouching and obliteration of the axillary fold. [2,4]
Ultrasound scan of the shoulder joint Thickening of the coracohumeral ligament. hypoechoic material surrounding the biceps brachii tendon (long head) at the rotator interval [3,4]
Magnetic resonance imaging (MRI) Indicated if symptoms don't improve after treatment of 3 months to rule out possible rotator cuff tear or intra-articular pathology. [3.4]
ESR/CRP Useful to rule out an inflammatory arthritis or polymyalgia rhematica [4]
References
  1. MANSKE,R.C, D.PROHASKA. Diagnosis and management of adhesive capsulitis.Curr Rev Musculoskelet Med[Online], Dec 2008, 1(3-4), 180–189. [viewed 16 March 2014]. Available from: doi: 10.1007/s12178-008-9031-6
  2. BINDER,A.I. et al.Frozen shoulder: an arthrographic and radionuclear scan assessment. Ann Rheum Dis[Online], Jun 1984, 43(3), 365–369. [viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1001346/
  3. WHITE,R.H et al. Shoulder Pain. West J Med[Online], Oct 1982, 137(4), 340–345. [viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989032/pdf/264_2010_Article_1038.pdf
  4. ANTHONY,E. Adhesive Capsulitis: A Review.Am Fam Physician[Online], 2011 Feb 15,83(4),417-422. [viewed 16 March 2014]. Available from: http://www.aafp.org/afp/2011/0215/p417.html

Investigations - Followup

Fact Explanation
Fasting Blood Sugar level Studies show an elevated incidence of diabetes in patients with adhesive capsulitis. This association should prompt possible testing of fasting blood sugar levels in most patients, particularly those presenting with bilateral disease and patients presenting with adhesive capsulitis who are younger than 45 years. [1]
References
  1. KAY,N.R, D.N.SLATER. Fibromatoses and diabetes mellitus. Lancet.[Online] 1981 Aug 8,2(8241),303–303. [viewed 16 March 2014]. Available from:http://www.sciencedirect.com/science/article/pii/S0140673681905444

Investigations - Screening/Staging

Fact Explanation
Magnetic resonance imaging (MRI) Useful in staging of the disease. Stage 1 - Mild thickening of the axillary pouch, which is only mildly hyperintense and moderate scarring of the rotator interval. Stage 2 - Moderately thickened, hyperintense capsule and mild hyperintensity in the rotator interval. Stage 3 - Mild thickening of the capsule, which is hypointense and mild scarring in the rotator interval. Stage 4 - The capsule is mildly thickened, redundant, and hypointense.Mild scarring in the rotator interval. MRI provides information that may assist the clinician in differentiating between the early and late stages.MRI can be used to diagnose all stages of adhesive capsulitis, including stage 1, where findings may be subtle on clinical examination. [1,2]
References
  1. CAROLYN,M.S. et al. Magnetic Resonance Imaging of Adhesive Capsulitis: Correlation with Clinical Staging.HSS J[Online], Sep 2008, 4(2), 164–169.[viewed 16 March 2014]. Available from: doi: 10.1007/s11420-008-9088-1
  2. CONNEL,D.,R. PADMANABHAN, R.BUCHBINDER. Adhesive capsulitis: role of MRI imaging differential diagnosis. Eur Radiol,[online]. 2002.12(8),2100–2106. .[viewed 16 March 2014]. Available from: http://link.springer.com/article/10.1007/s00330-002-1349-7#page-1

Management - General Measures

Fact Explanation
Reassurance and watchful waiting Because adhesive capsulitis is a self limiting condition,observation and reassurance alone can be considered in some patients after other differentials are excluded. But the patient must be told that it may take sometimes (months to even years) to resolve. So in many patients,this method can not be used.[1]
NSAIDs (Non-steroidal anti-inflammatory drugs) Anti inflammatory and analgesic effect.[1,2]
Oral corticosteroids Tapering course of oral prednisone is used for more severe cases. Initiate with 40-60 mg per day and is tapered by 10 mg every 4 - 7 days.This provides short-term benefit in pain relief and improved range of motion. [3]
Corticosteroid injections Subacromial or glenohumeral approach should be used. Ultrasound guided joint injections are recommended because of the high rate of inaccuracy when approaching blindly. [4,5]
Capsular distension injections The shoulder joint is injected with local anesthetic in attempt to stretch the capsule. This method is poorly tolerated because the procedure is painful. [5]
Physiotherapy Is very effective when using with corticosteroid injections. [6] Aggressive physical therapy can exacerbate pain and diminish adherence to the treatment plan. Initial therapy typically includes gentle range-of- motion exercises such as external rotation, forward flexion, crossover arm stretch. Ultrasound, massage, iontophoresis, and phonophoresis are also proven effective. [7]
References
  1. ANTHONY,E. Adhesive Capsulitis: A Review.Am Fam Physician [online] , 2011 Feb 15,83(4),417-422. [viewed 16 March 2014]. Available from: http://www.aafp.org/afp/2011/0215/p417.html
  2. MANSKE,R.C, D.PROHASKA. Diagnosis and management of adhesive capsulitis.Curr Rev Musculoskelet Med[online] , Dec 2008, 1(3-4), 180–189. [viewed 16 March 2014]. Available from: doi: 10.1007/s12178-008-9031-6
  3. BUCHBINDER,R. et al.Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial. Ann Rheum Dis[online] , 2004,63(11),1460–1469.[viewed 16 March 2014]. Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1754804/
  4. EUSTACE,J.A. et al.Comparison of accuracy of steroid placement with clinical outcome in patient’s with shoulder symptoms. Ann Rheum Dis[online] ,1997,56,59–63.[viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1752250/
  5. JONES,A. et al. Importance of placement of intra-articular steroid injections. Br Med J[online] , 1993,307,1329–30.[viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1679404/
  6. CARETTE,S. et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum[online] , 2003,48(3),829–838.[viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12632439
  7. JEWELL,D.V., D.L.RIDDLE, L.R.THACKER. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Ther[online] , 2009,89(5),419–429.[viewed 16 March 2014]. Available from: doi: 10.2522/ptj.20080250

Management - Specific Treatments

Fact Explanation
Manipulation under anesthesia (MUA) Surgical management options are considered when 6 - 12 weeks of conservative treatment does not improve the symptoms. MUA involves manipulating the humerus to disrupt adhesions when the patient is under general anesthesia.This has been found to be effective when followed by physiotherapy. [1] Risks - Iatrogenic proximal humeral fracture, glenohumeral dislocation, and rotator cuff tearing. Best to avoid in patients with osteoporosis or significant osteopenia, with a history of glenohumeral instability. [2,3]
Arthroscopic release and repair Effective in treating recalcitrant adhesive capsulitis.Great improvement in pain, ROM and shoulder function have been demonstrated.[1]
Open Release Indicated for failure of arthroscopic release. Approached through a deltopectoral region.[1,3]
References
  1. ANTHONY,E. Adhesive Capsulitis: A Review.Am Fam Physician [Online], 2011 Feb 15,83(4),417-422. [viewed 16 March 2014]. Available from: http://www.aafp.org/afp/2011/0215/p417.html
  2. ANTON,H.A. Frozen shoulder. Can Fam Physician [Online], 1993,39,1772– 8. [viewed 16 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2379805/
  3. MANSKE,R.C, D.PROHASKA. Diagnosis and management of adhesive capsulitis.Curr Rev Musculoskelet Med [Online], Dec 2008, 1(3-4), 180–189. [viewed 16 March 2014]. Available from: doi: 10.1007/s12178-008-9031-6