Adhesive Capsulitis

Nkechi Nweke
Oceania University of Medicine
July 2022
Anatomy

The shoulder is formed by articulations of the humerus, clavicle and scapula. Four joints are contained within the
shoulder - glenohumeral, sternoclavicular, acromioclavicular and scapulothoracic joints.

The glenohumeral joint is the main articulation of the shoulder joint. It is a multiaxial ball and socket synovial joint
formed by the humeral head and glenoid cavity of the scapula. The humeral head is much larger than the glenoid
cavity. To decrease the disproportion, the glenoid cavity is deepened by a fibrocartilage rim (glenoid labrum).
Movements at the glenohumeral joint include abduction, adduction, flexion, extension, internal rotation, external
rotation and circumduction.

Rotator cuff muscles, ligaments and glenoid labrum contribute to stability at the shoulder joint. Subacromial and
subscapular bursae are the main bursae providing cushioning between tendons and other joint parts.

The shoulder joint is supplied by anterior and posterior circumflex arteries (branches of axillary artery) with
contribution from the suprascapular artery ( branch of thyrocervical trunk). Veins with corresponding names drain
the joint .
Innervation is provided by suprascapular, axillary and lateral pectoral nerves.
Adhesive capsulitis (also known as frozen shoulder) is a term used in describing a stiff, painful and dysfunctional
shoulder. It is a debilitating and poorly understood pathological condition of the shoulder characterized by
fibrosis and contracture of the glenohumeral joint capsule. Affected persons suffer from loss of active and passive
movements in multiple planes.

Epidemiology

The prevalence of adhesive capsulitis in the general population is estimated to be 2 to 5%. Persons between ages
40 and 70 are commonly affected. About 70% of affected persons are women. Among the affected population, 20
to 30% of individuals would go on to develop adhesive capsulitis in the other shoulder.

Diabetes is the most alarming risk factor with up to 20% prevalence among this group.
Etiology

Adhesive capsulitis has been linked to various predisposing conditions such as diabetes, previous surgery,
inflammatory disease, trauma, shoulder maladies, Parkinson disease, cervical spine disease, ischemic
heart disease, hypothyroidism and hyperthyroidism:

Risk Factors
- Female gender
- Age between 40 and 70 years
- Thyroid disease
- Diabetes
- Trauma
- Stroke or MI
- Prolonged immobilization
- Autoimmune conditions
Pathophysiology

The pathophysiology of adhesive capsulitis is not well understood. The main cause is thought to be a primary

fibrotic disorder driven by an inflammatory process. Progression of the fibrotic process will eventually cause

thickening and contracture of the glenohumeral joint capsule . Fibrotic rotator cuff interval, thickened

coracohumeral ligament and loss of capsule synovial layer are also characteristics of the condition.

Microvascular disease such as diabetes may impair collagen repair and predispose patients to adhesive
capsulitis.
Presentation

- Vague, dull shoulder pain which is worse at night and exacerbated by lying on affected side
- Pain with shoulder movement, affecting ADLs
- Stiffness with decreased ROM especially in second (frozen ) stage
- Limited ROM especially abduction and external rotation
.

Physical Examination

- Observe patient’s posture while sitting on a stool ( are they leaning to one side or holding the neck
because of pain?)
- Deep palpation will cause tenderness at deltoid insertion, over anterior and posterior capsules
- Assess active and passive ROM. Compare with unaffected shoulder. Limited abduction and external
rotation are the most prominent findings
Investigations

Adhesive capsulitis is a clinical diagnosis. If physical examination is insufficient, a lidocaine injection test can be
done. Injecting lidocaine into the subacromial space will provide pain relief and increased ROM for patients
with subacromial pathology. Adhesive capsulitis patients will continue to have pain with active and passive
movements.
Imaging exams can be done to rule out other pathology but they are not specific for adhesive capsulitis.

Differentials
- Osteoarthritis
- Synovitis
- Malignancy
- Fracture
- Polymyalgia Rheumatica
- Rotator Cuff Tendinopathy
- Tendinitis
- Cervical Radiculopathy
- Shoulder impingement
- Bursitis
Stages of Adhesive Capsulitis

Stage 1 : painful shoulder which is worse at night, with preserved ROM

Conservative management
- Physical therapy
- Pharmacological therapy: NSAIDS, oral glucocorticoids, intra articular steroid injection, sodium
hyaluronate injection, botulinum toxin type A, suprascapular nerve block, hydrodilation (intra
articular distension)
- Alternative therapies : whole body cryotherapy, extracorporeal shockwave therapy

Surgical management: reserved for refractory or recalcitrant cases

The main complication arising from adhesive capsulitis is shoulder pain and stiffness resulting in loss of
function. Fractures, axillary nerve injuries and tendon ruptures have been reported following shoulder
manipulation.

Prognosis

Adhesive capsulitis can be treated with physiotherapy. Resolution typically happens within 3 years. Long term
stiffness and pain have been reported following conservative treatment. Persistent symptoms have been
reported in 40% of cases; long term disability in 15% of cases and permanent loss of function in 7-15% of cases.
References

1. Adhesive Capsulitis (Frozen Shoulder): Practice Essentials, Problem, Epidemiology. (2020).

2. de la Serna, D., Navarro-Ledesma, S., Alayón, F., López, E., & Pruimboom, L. (2021, May 11). A
Comprehensive View of Frozen Shoulder: A Mystery Syndrome [Review of A Comprehensive View of
Frozen Shoulder: A Mystery Syndrome]. Frontiers; Frontiers in Medicine.
https://www.frontiersin.org/articles/10.3389/fmech.2019.00057/full

3. Frozen Shoulder | Adhesive Capsulitis • Easy Explained - OrthoFixar 2022. (2021, October 17).
https://orthofixar.com/sports-medicine/frozen-shoulder/#Operative_Treatment

4. Page, R. S., McGee, S. L., Eng, K., Brown, G., Beattie, S., Collier, F., & Gill, S. D. (2019). Adhesive
capsulitis of the shoulder: protocol for the adhesive capsulitis biomarker (AdCaB) study. BMC
Musculoskeletal Disorders, 20(1). https://doi.org/10.1186/s12891-019-2536-x

5. Patel, R., Urits, I., Wolf, J., Murthy, A., Cornett, E. M., Jones, M. R., Ngo, A. L., Manchikanti, L.,
Kaye, A. D., & Viswanath, O. (2020). A Comprehensive Update of Adhesive Capsulitis and
Minimally Invasive Treatment Options. Psychopharmacology Bulletin, 50(4 Suppl 1), 91–107.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901130/