Adhesive Capsulitis

Question 1

What is adhesive capsulitis?

Answer 1

Adhesive capsulitis (frozen shoulder) is a condition in which the glenohumeral joint capsule becomes contracted and adherent to the humeral head. This can result in shoulder pain and a reduced range of movement in the shoulder.

Question 2

Who is commonly affected by adhesive capsulitis?

Answer 2

It affects approximately 3% of the population, it is more common in women, and peak onset is between 40-70yrs old. Those who have previously been affected by adhesive capsulitis are more susceptible to developing the condition in the contralateral shoulder.

Question 3

Briefly differentiate between primary and secondary adhesive capsulitis

Answer 3

Adhesive capsulitis may be categorised as primary or secondary:

• Primary adhesive capsulitis (idiopathic)
• Secondary adhesive capsulitis: associated with rotator cuff tendinopathy, subacromial impingement syndrome, biceps tendinopathy, previous surgery or trauma or known joint arthropathy

Question 4

Briefly describe the pathophysiology of adhesive capsulitis

Answer 4

Adhesive capsulitis is often associated with inflammatory diseases and currently theory suggests that it may have an autoimmune element.

Question 5

Name the 3 bursae of the shoulder

Answer 5

Question 6

What are the clinical features of adhesive capsulitis

Answer 6

Patients will describe a generalised deep and constant pain of the shoulder (which may radiate to the bicep), that often disturbs sleep. Associated symptoms include joint stiffness and a reduction in function.

On examination, there may be a loss of arm swing and atrophy of the deltoid muscle. Generalised tenderness on palpation is common.

The patient will have a limited range of motion, principally affecting external rotation and flexion of the shoulder (a full range of motion should prompt consideration of alternative differential diagnoses).

Question 7

What investigations should be ordered for adhesive capsulitis?

Answer 7

The diagnosis of adhesive capsulitis is typically a clinical one, therefore can be made by clinical features alone.

Plain film radiographs are generally unremarkable, but importantly can be used to rule out acriomioclavicular pathology or atypical presentations of fractures.

MRI imaging can reveal a thickening of the glenohumeral joint capsule in adhesive capsulitis, but also can be used to rule out other conditions affecting the shoulder, such as subacromial impingement syndrome.

Question 8

What is shown on the MRI scan?

Answer 8

MRI scan showing thickening of the glenohumeral joint capsule.

Question 9

Briefly describe the conservative management of adhesive capsulitis

Answer 9

Adhesive capsulitis is a self-limiting condition however recurrence is not uncommon. Recovery usually occurs over months to years and a proportion of patients will never recover full range of movement.

Initial management of the patient involves education and reassurance. Patients should be encouraged to keep active; all patients should receive physiotherapy and advice concerning appropriate shoulder exercises.

Management of pain initially begins with simple analgesics. Glenohumeral joint corticosteroid injections may be considered for those patients failing to improve.

Question 10

Briefly describe the surgical management for adhesive capsulitis

Answer 10

For patients with no improvement following prolonged engagement with full conservative treatment efforts and when symptoms significantly affect quality of life, surgical intervention may be considered.

Potential surgical interventions include joint manipulation under general anaesthetic to remove capsular adhesions to the humerus, arthrogaphic distension, or surgical release of the glenohumeral joint capsule.

Question 11

What are the complications of adhesive capsulitis?

Answer 11

A small proportion of patients will never regain a full range of motion but will regain movement beyond that required to perform activities of daily living.

In some patients the progression of symptoms may persist beyond two years and adhesive capsulitis may recur in the contralateral shoulder.

Question 12

What differentials should be considered for adhesive capsulitis?

Answer 12

1. Acromioclavicular pathology
2. Subacromial impingement syndrome
3. Muscular tear
4. Autoimmune disease

Question 13

What is acromioclavicular pathology? How does it differ to adhesive capsulitis pain?

Answer 13

Acromioclavicular pathology (e.g. acriomioclavicular joint injury, acromioclavicular arthritis, glenohumeral arthritis): a more generalised pain may be present with weakness and stiffness related to pain.

Question 14

What is subacromial impingement syndrome? How does it differ to adhesive capsulitis pain?

Answer 14

Subacromial impingement syndrome (rotator cuff tendinopathy, subacromial bursitis): may present with preserved passive movement and history of repetitive overuse/external compression of subacromial space risk factors.

Question 15

What is a muscular tear? How does it differ to adhesive capsulitis?

Answer 15

Muscular tear (rotator cuff tear, long head of biceps tear): the weakness often persists when the shoulder pain is relieved.

Question 16

What is autoimmune disease? How does it differ from adhesive capsulitis?

Answer 16

Autoimmune disease (polymyalgia rheumatica, rheumatoid arthritis, systemic lupus erythematous): may present with a polyarthropathy and systemic symptoms.