Adhesive capsulitis or Frozen shoulder describes a pathological process in which the body forms excessive scar tissue or adhesions across the glenohumeral joint (shoulder), leading to stiffness, pain and dysfunction. The most common limitations in range of motion are flexion, abduction, and external rotation. Approximately 70 % of frozen shoulder patients are women, however, males with frozen shoulder are at greater risk for longer recovery and greater disability. Painful stiffness of the shoulder can adversely affect activities of daily living and consequently impair quality of life.
Types of Frozen Shoulder
Adhesive capsulitis can be primary or secondary. Primary (or idiopathic) adhesive capsulitis can occur spontaneously without any specific trauma or inciting event. Secondary adhesive capsulitis is often observed after periarticular fracture dislocation of the glenohumeral joint or other severe articular trauma. It can also be a severe complication after open or arthroscopic shoulder surgery, including rotator cuff repair and shoulder arthroplasty.
Diagnosis of Frozen Shoulder
Adhesive shoulder capsulitis is a clinical diagnosis made on the basis of medical history and physical exam and is often a diagnosis of exclusion.
Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) may reveal thickening of capsular and pericapsular tissues as well as a contracted glenohumeral joint space. Dynamic sonography may reveal thickening of the joint capsule and limited sliding movement of the supraspinatus tendon.
Risk Factors of Frozen Shoulder
Risk factors for adhesive capsulitis include female sex, age over 40 years, preceding trauma, HLA-B27 positivity and prolonged immobilization of the glenohumeral joint. It is estimated that 70% of patients with adhesive shoulder capsulitis are women.
Adhesive capsulitis is associated with diabetes, thyroid disease, cerebrovascular disease, coronary artery disease, autoimmune disease and Dupuytren’s disease.
Stages of Frozen Shoulder
Stage I : Freezing, synovitis (duration 3 – 9 months) : Patients present with a primary complaint of shoulder pain, especially at night, although they have preserved motion and begin to develop stiffness.
Stage II : Frozen (duration 4 – 12 months) ; Patients present with a global loss of ROM and pain at the extremes of motion.
Stage III : Thawing (between 12 and 42 months) : There is persistent stiffness but minimal pain as synovitis has resolved. With pain controlled, patients may begin to exhibit slow improvement in shoulder mobility
Contracture of the glenohumeral capsule is the hallmark of adhesive capsulitis. Findings include loss of the synovial layer of the capsule, adhesions of the axillary to itself and to the anatomical neck of the humerus, and overall decreased capsular volume. A contracted coracohumeral ligament is considered the essential finding in adhesive capsulitis.
The goal of treatment of adhesive capsulitis is to restore the shoulder to a painless and functional joint.
Physical therapy interventions
- Transcutaneous electrical stimulation (TENS)
- Low-power laser therapy
- Hot pack therapy
Extracorporeal Shockwave Therapy
The use of ESWT seems to have positive effects on treatment, quicker return to daily activities, and quality-of-life improvement on frozen shoulder. Patients with frozen shoulder can take advantage of ESWT because of its noninvasive, safe nature, low costs, no need for hospitalization, fewer visits of patient in the hospital, and the lack of significant adverse events during the treatment.
Passive Range of Motion (PROM) Exercise
Adhesive capsulitis involves fibrotic changes to the capsuloligamentous structures, continuous passive motion is thought to help elongate collagen fibers.
Joint mobilization is an effective intervention for adhesive capsulitis. In particular, posterior glide mobilization was determined to be more effective than anterior glide for improving external rotation range of motion in patients with adhesive capsulitis.
Soft Tissue Mobilization
Soft tissue mobilization and deep friction massage may benefit adhesive capsulitis patients. Deep friction massage using the Cyriax method to superficial heat and diathermy in treatment of patients with adhesive capsulitis. The inferior glenohumeral capsule and pectoral fascia are often restricted, as well as the insertion of the latissimus dorsi and subscapularis.
The most commonly prescribed therapeutic exercises for adhesive capsulitis are active-assisted range of motion (AAROM) exercises. Generally, these exercises are performed for flexion, abduction and external rotation ranges of motion which are frequently the most limited.
Resistive exercises typically include strengthening of the scapular stabilizers and rotator cuff, when range of motion has progressed enough for strengthening to be an appropriate intervention. Patients with adhesive capsulitis have significantly weaker lower trapezius muscles compared to asymptomatic controls.
The “Shoulder Sling” exercise can be used to help re-train the initial setting phase of the rotator cuff when initiating abduction.
Corticosteroid intra-articular injection
Intra-articular corticosteroid injection has been observed to offer faster and superior improvement in symptoms compared to oral steroid treatment. Intra-articular steroid injection decreases fibromatosis and myofibroblasts in adhesive shoulders.
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