Adhesive Capsulitis (Frozen Shoulder)

A condition of varying severity characterized by the gradual development of global limitation of

active and passive shoulder motion where radiographic findings other than osteopenia are absent.
– American Academy of Orthopaedic Surgeons

A condition of uncertain etiology characterized by significant restriction of both active and

passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder. -
American Shoulder and Elbow Surgeons

SUBJECTIVE
Insidious onset of vague, dull pain at the deltoid insertion
Pain with shoulder movement
Nagging pain at night, with sleep deprivation and the inability to sleep on the affected side
Marked limitation of active and passive shoulder rotation, particularly external rotation. The
loss of passive range of motion (ROM) is a critical element in establishing the diagnosis of a true
frozen shoulder.

Pain leads to significant disability, affecting the activities of daily living, work, and leisure.

Patients may be divided into 2 categories: primary or secondary adhesive capsulitis. A patient
meets the criteria of primary or secondary FSS if painful, restricted active and passive
glenohumeral and scapulothoracic motion occurs for at least 1 month and has either reached a
plateau or worsened.

Patients with primary frozen shoulder have no significant findings in the history, clinical
examination, or radiographic evaluation to explain their motion loss and pain.

Classically, symptoms of primary frozen shoulder have been divided into three phases: freezing
(painful), frozen (stiffening), and thawing.
1) Freezing
- gradual onset of diffuse shoulder pain lasting from weeks to months
2) Frozen
- complain of stiffness and severe loss of shoulder motion. The pain will be less
pronounced. Patients will complain about the inability to reach over their head, to
their side, and across their chest with the affected arm, or to scratch their back or put
on a coat.
- Most patients lose glenohumeral external rotation, internal rotation, and abduction
during this phase.
- May last up to 1 year
3) Thawing
- weeks to months
- constitutes a period of gradual motion improvement.

In contrast to patients with primary FSS, patients with secondary FSS describe an event that
preceded the onset of shoulder symptoms, such as the following:
 Upper extremity trauma (eg, shoulder surgery, rotator cuff tear, proximal humerus facture)
 Immobilization (eg, cardiothoracic surgery, neurosurgery)
 Metabolic/endocrine (eg, thyroid disease, diabetes mellitus, autoimmune disease,
hyperlipidemia)
  Neurologic (eg, stroke, Parkinson disease)
 Cardiac disease (eg, ischemic heart disease, hypertension)
 Drugs (eg, protease inhibitors, antiretrovirals, immunizations, fluoroquinolones)
 Malignancy

The early symptoms and signs of frozen shoulder can be confused with subacromial pathology
(eg, rotator cuff tendinopathy, subacromial bursitis, impingement syndrome). In all these
conditions, patients report pain and limited active range of motion. However, several facets of the
clinical presentation and examination help to distinguish frozen shoulder from these conditions.
Patients with subacromial pathology often give an occupational or athletic history of heavy lifting
or repetitive movements, especially above shoulder level. Patients with rotator cuff tendinopathy
and subacromial bursitis often complain of activity-related pain and problems performing usual
activities. In some cases, symptoms may occur in the non-dominant arm and in non-manual
workers.

Age is another distinguishing factor. Frozen shoulder is unlikely in patients younger than 40 years
of age, and patients older than 70 are more likely to have rotator cuff tears or glenohumeral
osteoarthritis.

OBJECTIVE
 Tenderness at the deltoid insertion and over the anterior capsule and posterior capsule with
deep palpation.
 Compensatory scapulothroacic motion can create pain around the medial scapula. Foward
flexion, abduction, and internal and external rotation of the shoulder should be assessed.
 Active and passive range of motion at the glenohumeral joint will be reduced, compared with
the unaffected shoulder.
 Limitation of external rotation and abduction will be the most prominent findings. Patients
have difficulty placing their hand on their buttock.
 Limitations in shoulder motion are more often due to pain in patients with subacromial
pathology, as opposed to the mechanical restrictions found with frozen shoulder, particularly
in its later stages. In contrast, patients with a painful subacromial condition demonstrate
limited active range of motion while passive range of motion is preserved.
 Sensitivity on a specific spot on the front of the shoulder, called on the tip of the coracoid
process. This occurs in more than 95% of cases of adhesive capsulitis and only 10-15% in
other kinds of shoulder pain

Injection test — An injection test may be helpful in establishing the diagnosis if, following a
careful history and physical examination, the clinician continues to have difficulty distinguishing
between frozen shoulder and subacromial conditions. In patients with frozen shoulder, active
movement restriction and the palpable, painful end detected with passive motion testing persist
after injection of an anesthetic into the subacromial (but extra-articular) space. In contrast,
patients with pain from focal subacromial pathology (eg, rotator cuff tendinopathy, subacromial
bursitis) generally experience pain relief and improved range of motion.

ASESSMENT

Clinical diagnosis, so imaging studies are not indicated

However, more recent studies are moving toward defining the criteria for imaging studies to aid
in the staging of FSS. Common findings in FSS are thickening of the coracohumeral and inferior
glenohumeral ligaments. Zappia reports that rotator interval fat pad obliteration has 100%
specificity for adhesive capsulitis.
Plain radiograph, ultrasound, and MRI can be used to rule out other conditions and to confirm the
likelihood of the correct diagnosis.

PLAN

Goals: to relieve pain and restore movement and shoulder function

• Regain normal shoulder range of motion

• Control pain
• Regain normal upper extremity strength and endurance
• Achieve the level of function based on the orthopedic and patient goals

1. Physiotherapy and home exercise are first-line treatments for all stages of FSS. Patients with
mild disease and those early in the recovery phase of frozen shoulder may benefit from
performing gentle range of motion exercises (eg, pendulum swings) provided they do not cause
undue discomfort.

2. These are often combined with anti-inflammatory medications and glenohumeral joint
corticosteroid injection.
- NSAIDS
- Low-dose oral corticosteroids is recommended only in cases of severe refractory frozen
shoulder that has either been present for an extended period (ie, longer than 2 months) or is
causing significant pain
- A local corticosteroid injection can be used in conjunction with oral NSAIDs or oral
corticosteroids. 20 mg triamcinolone as an optimal dose

3. Extracorporeal shockwave therapy (ESWT) shows promise as a therapy for adhesive

capsulitis. ESWT compared favorably with oral steroids as a short-term treatment for primary adhesive
capsulitis in a prospective, randomized, controlled, single-blind clinical trial by Chen et al in 40 patients. From
the fourth week of treatment, the ESWT group showed significant improvement superior to that in the steroid
group; at the sixth week, improvement in activities of daily living (ADL) achieved significance and was better
than that in the steroid group.
Results of an observational study by Santoboni and colleagues suggest that ESWT may offer a safer alternative to
steroid injections or surgery for treatment of adhesive capsulitis in patients with diabetes. In their study, which included
50 consecutive patients with an overall mean pain duration of 15.7 months, significant functional improvements
compared with baseline were evident at 2 months, with further amelioration at 4 and 6 months.
All patients received ESWT once a week for 3 weeks, with 2400 shots in an anterior-to-posterior direction on the
anterior shoulder joint using a low/moderate-energy flux density (0.06–0.14 mJ/mm2, depending on individual pain
tolerance). No relevant adverse effects were reported.

4. Surgical therapy is reserved for patients who do not respond to conservative management and
should be deferred as long as possible.
The photographs above show common motion restrictions that are found with frozen shoulder.
Note how the affected left shoulder is limited in external rotation (A), abduction (B), and internal
rotation (C), compared with the unaffected shoulder (photographs D, E, and F). Photographs A,
B, D, and E depict passive glenohumeral motion while the scapula is stabilized.
Other shoulder problems that could be confused with adhesive capsulitis

These are presented roughly in order of how much they can seem like frozen shoulder, briefly explaining them
and highlighting the major differences:

Rotator cuff tendinopathy or tear. The rotator cuff is a group of four muscles that surrounds the shoulder joint like
a “cuff,” and that cuff is anatomically overlapping the joint capsule that gets inflamed in frozen shoulder —
which is why rotator cuff problems can be difficult to distinguish from frozen shoulder. Confusing things even
more, rotator cuff trouble might make movement uncomfortable, as with frozen shoulder, but not necessarily.
Rotator cuff abnormalities and lesions increase steadily later in life, like arthritis, but are also amazingly
common in pain-free younger people — in other words, even there’s an “obvious” problem on an X-ray or
MRI, it ain’t necessarily the problem.31 But the rotator cuff can hurt, and when it does, it mostly
limit active movement, whereas frozen shoulders are frozen even when you are relaxed and someone else tries
to moves your shoulder for you (passive movement). And tears tend to happen suddenly with exertion, a clear
“oh shit” moment of injury. And with tears or tendinitis, the pain is usually limited to more specific spots and
movements than with frozen shoulder.

Subacromial and subdeltoid bursitis are closely related to rotator cuff tendinitis, but instead of tendons they
affect bursae (the anatomical padding between tendons and other structures).

Arthritis of the big shoulder joint mostly occurs beyond middle age, and usually develops more slowly-but-
steadily, and isn’t as severe. An X-ray will show clear signs of joint degeneration that won’t be seen with
adhesive capsulitis. Shoulder arthritis often involves a history of injury.

Acromioclavicular arthropathy is degeneration of the joint at the outside end of the collar bone. It does not really
affect shoulder range of motion, the pain is more specific to that superficial joint, and it’s usually associated
with a history of overuse and injury, usually athletic.

Tendinitis of the biceps tendon. Tenderness sticks to the front of the shoulder with this condition. Biceps
contraction is painful, but other movements are normal.

Cervical disk degeneration, basically arthritis of the spine, can cause pain, weakness, and numbness that spreads
out into the shoulder and can make it seem “frozen,” but this problem usually also spreads further: symptoms
in the hand and wrist will usually be more prominent with this problem.

Autoimmune diseases like lupus or rheumatoid arthritis can affect many joints in the body, including the
shoulder — but they usually do affect multiple joints, and cause several other health problems that obviously
set them apart.

Cancer is one of the least likely causes of frozen-shoulder-ish pain, but a tumour in or near the joint is a
possibility. Watch out for other signs of failing health, especially night sweats and weight loss and shortness of
breath.