Case 27 A 51-year-old woman presents with a 6-month history of progressive right shoulder pain without specific predisposing injury. She has a benign medical history, and complains only of shoulder pain with some loss of motion. She denies any numbness, but states she occasionally has very painful episodes while trying to perform certain activities at the limits of her effective shoulder motion. The patient demonstrates no tenderness, swelling, or local warmth around the shoulder. Her active forward flexion is 100 degrees and her passive forward flexion is 120 degrees. She has passive external rotation of 10 degrees and active external rotation of 0 degrees. Her internal rotation is decreased about 10 vertebral levels. She has normal strength. Translation testing of her shoulder fails to demonstrate any evidence of instability. She is otherwise neurovascularly intact. 1. Chronic impingement syndrome 2. Full-thickness rotator cuff tear 3. Cervical radiculopathy 4. Adhesive capsulitis An anteroposterior (AP), axillary, and scapular Y view fail to reveal any obvious abnormalities. Adhesive Capsulitis. The patient’s history and physical findings are typical of idiopathic adhesive capsulitis. Progressive pain, along with significant losses of forward flexion, external rotation, and internal rotation help support the diagnosis. However, adhesive capsulitis must be thought of as a diagnosis of exclusion. The diagnosis can be confirmed only after other conditions that mimic frozen shoulder are ruled out. Large rotator cuff tears, subacromial impingement, posterior shoulder dislocation, cervical arthritis, neuromuscular disease, and Pancoast’s tumor can all present like adhesive capsulitis. An important diagnostic test to help differentiate between frozen shoulder and impingement syndrome is the impingement test. Seven to 10 cc of local anesthetic is injected under sterile conditions into the subacromial space. After a period of 5 to 10 minutes, the patient is reassessed. When impingement tendinitis is the etiology of the patient’s symptoms, response generally allows for not only symptomatic reduction in pain, but also a significant increase in motion in all planes. Conversely, when no improvement in pain or motion is seen following injection, idiopathic adhesive capsulitis is considered the working diagnosis while other etiologies are excluded. Magnetic resonance imaging is rarely helpful in the diagnosis of frozen shoulder, but is valuable to rule out other causes of significant motion loss in the shoulder. These causes include large rotator cuff tears, severe subacromial impingement, and occult tumors. Once other etiologies to account for the signs and symptoms are ruled out, a diagnosis of idiopathic adhesive capsulitis is made. PEARLS • Assessment of passive rotation of the glenohumeral joint is key to making an accurate diagnosis of frozen shoulder. Every patient with a history of shoulder pain should be evaluated for passive internal and external rotation. This loss of motion easily and clearly distinguishes frozen shoulder from almost every other pathologic shoulder condition. • If manipulation is to be carried out on a shoulder, care must be taken to avoid undue torque on the humerus during the manipulation. For this reason, passive forward flexion should be carried out first, followed by rotational manipulation so as to reduce the rotational torque applied to the shoulder. Also, a preoperative radiographic assessment of the relative osteopenia present is important in planning for a possible manipulation either with or without arthroscopic capsular release. • Intraarticular injection of corticosteroid following the closed manipulation and/or arthroscopic capsular release may reduce the postoperative inflammatory response and help in maintenance of shoulder motion. • Release and even excision of a portion of the rotator interval capsule not only is felt to assist in motion recovery, but also may aid in maintenance of motion postoperatively. • Particular attention to portal placement and the use of blunt trocars only is strongly recommended to minimize iatrogenic articular cartilage injury to both the humeral head and glenoid in this extremely tight joint space. Frozen shoulder typically occurs in the sixth decade of life. It has been found to be associated with a variety of metabolic, neurologic, and neoplastic medical conditions. As many as 20% of diabetics will develop adhesive capsulitis at some point during their lives. Frozen shoulder is characterized by a series of phases the disease progresses through. It is generally considered to be a self-limited disease, although some investigators report significant losses of motion even 6 to 10 years after the diagnosis is made. The three phases of frozen shoulder are (1) freezing, (2) frozen, and (3) thawing. However, identifying the phase that an individual patient is in at the time of presentation is difficult. The length of time that one phase lasts before a subsequent one begins is highly variable. The duration of the painful freezing phase is classically described as 2 to 9 months. This phase corresponds with an acute inflammatory process that can be seen arthroscopically. Patients often have severely limited function of the shoulder during this phase, not only due to static blocks to motion, but also as a result of the significant pain in and around the shoulder. The frozen phase develops as the freezing phase abates. The frozen phase generally lasts for 4 to 12 months. Progressive loss of motion and capsular fibrosis are typical of this phase. Pain is often reduced relative to the initial freezing phase. Physical examination of the shoulder during this phase generally reveals significant motion restrictions, with a firm end point to motion in any plane. Scapulothoracic symptoms are also common in this phase, as a result of compensatory motion of the scapulothoracic articulation. The final thawing phase begins as the frozen phase abates and is characterized by slow improvement in shoulder motion and comfort. The length of this phase is again variable, lasting anywhere from 1 month to several years. A number of studies have demonstrated that, whereas pain complaints generally abate completely over time, persistent losses of motion are not uncommon after complete resolution of adhesive capsulitis. It is important to remember that frozen shoulder is generally considered a self-limited disease. This implies that conservative treatment directed at reducing or eliminating symptoms, allowing the disease process to run its course, will often lead to full recovery with minimal morbidity. As a result, the authors always perform a gentle, organized exercise program on patients diagnosed with idiopathic adhesive capsulitis. This organized exercise program is overseen by a therapist with specific instructions that the therapy be painless. Aggressive range of motion exercises will only worsen the inflammatory process and make symptoms more severe. A detailed discussion about adhesive capsulitis is held with the patient at the time of diagnosis in an effort to explain the expected time course for resolution and the options for treatment. Other specific instructions regarding exercises and treatment are also given. These instructions include recommendations regarding capsular stretching activities, such as a regular schedule of walking while swinging the arm with a 1-pound weight in the hand so as to help stretch the inferior capsule. Nonsteroidal antiinflammatory medicines, and occasionally an intraarticular corticosteroid injection, are given at the initiation of therapy. Exercises are continued for a minimum of 3 months before surgical options are considered. Nevertheless, in patients who fail to improve or who worsen despite these interventions, arthroscopic surgery is seriously considered. PITFALLS • Failure to recognize frozen shoulder early in its presentation, while motion is still near normal, will delay effective treatment. Aggressive exercises for patients presumably suffering from impingement symptoms will only serve to inhibit recovery in patients actually suffering from adhesive capsulitis. This emphasizes the importance of careful assessment of shoulder motion by comparison to the contralateral shoulder. Another important diagnostic test to help identify frozen shoulder is the impingement test. Subacromial injection of local anesthetic usually does not improve symptoms attributable to adhesive capsulitis. • Inadequate access to the inferior recess of the glenohumeral joint at the time of arthroscopic capsular release will lead to either an inadequate capsular release or potentially a serious neurovascular injury.
History and Physical Examination
Differential Diagnosis
Radiologic Findings
Diagnosis
Surgical Management
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