Introduction
- Jo A. Hannafin, MD, PhD
- Theresa A. Chiaia, PT, DPT
- A. Simone Maybin, BS, NSCA-CPT
- Theresa A. Chiaia, PT, DPT
Epidemiology
- •
Primary adhesive capsulitis affects 2% to 5% of the general population
- •
Patient age, 40 to 65 years old
- •
Incidence, higher in females than in males
- •
Nondominant arm is more frequently involved
- •
Athletes (not sport specific) and nonathletes equally affected
Pathophysiology
Intrinsic Factors
- •
The following intrinsic factors may play a role in the development of primary adhesive capsulitis:
- •
Angiogenesis and synovitis consistent with inflammation
- •
- •
Secondary adhesive capsulitis and restriction of glenohumeral range of motion may result from:
- •
Rotator cuff tendonitis
- •
Rotator cuff tears
- •
Calcific tendonitis
- •
Contracture of the rotator cuff interval
- •
Subacromial scarring
- •
Inflammation of the long head of the biceps tendon and its synovial sheath
- •
Extrinsic Factors
- •
Trauma is the only known extrinsic factor implicated in the development of adhesive capsulitis.
- •
Patients with diabetes mellitus are at greater risk of developing adhesive capsulitis, with a prevalence between 10% and 20%
- •
Although more rare, both thyroid dysfunction and Parkinson disease are also associated with the development of adhesive capsulitis
Classic Pathological Findings
- •
General pathological findings are synovial hyperplasia and capsular fibrosis further characterized by:
- •
Elevated cytokine expression in shoulder capsule including transforming growth factor-β (TGF-β), platelet-derived growth factor, and hepatocyte growth factor
- •
Excess accumulation and propagation of fibroblasts (Type I and II collagen)
- •
- •
Specific pathological findings vary dependent upon the current stage of the patient. These are further described in Table 8-1 .
Table 8-1
Stages of Adhesive Capsulitis
Arthroscopic Appearance
Biopsy
Stage 1
(Preadhesive)
Fibrinous synovial inflammatory reaction
No adhesions or capsular contracture
Rare inflammatory cell infiltrate
Hypervascular, hypertrophic synovitis
Normal capsular tissue
Stage 2
(Freezing)
Christmas tree synovitis
Some loss of axillary fold
Hypertrophic, hypervascular synovitis
Perivascular, subsynovial capsular scar
Stage 3
(Frozen)
Complete loss of axillary fold
Minimal synovitis
Hypercellular, collagenous tissue with a thin synovial layer
Similar features to other fibrosing conditions
Stage 4
(Thawing)
Fully mature adhesions
Identification of intraarticular structures difficult
Not reported
Clinical Presentation
History
- •
Insidious onset without a definitive action or event causing symptoms
- •
Progressive increase in pain with development of sleep-disturbing night pain
- •
Deep achy pain at rest with acute intense pain associated with quick motion or rapid stretch
- •
ROM is initially limited by pain, not capsular contracture. It then progresses to global stiffness shoulder.
- •
Initial loss of external and internal rotation
- •
Passive and active motions are more restricted owing to pain at or before end range secondary to muscle guarding.
Physical Examination
Abnormal Findings
- •
Patients with adhesive capsulitis will differ in motion limitations dependent upon their current stage (1 through 4) ( Table 8-2 ).
Table 8-2
Clinical Signs and Symptoms of Adhesive Capsulitis
Symptoms
Signs
Stage 1
(Preadhesive)
Achy pain at rest referred to deltoid insertion; sharp pain with movement
Pain at night
Capsular sign on deep palpation
Empty end feel = pain stops PROM before resistance felt by clinician
Full motion under anesthesia
Stage 2
(Freezing)
Persistence of pain; increased night pain
Pain extends to upper trapezius secondary to compensatory shrugging
Progressive limitation of motion with ADLs
Motion restricted in capsular pattern; ROM reveals a capsular end feel. Forward flexion, abduction, internal and external rotation
Pain at the end of the ROM
Some improvement in motion under anesthesia
Stage 3
(Frozen)
Profound limitation of motion with ADLs
Pain present at the end of range of motion only
Resistance to ROM felt before pain
Significant loss of motion
Tethering at ends of motion
No improvement under anesthesia
Stage 4
(Thawing)
Minimal pain
Slow, steady improvement in ROM with ADLs
Significant motion loss
Gradual improvement in motion
Pertinent Normal Findings
- •
Strength deficits are generally not present, in contrast to impingement and rotator cuff disease.
- •
No significant muscle atrophy
Imaging
- •
Plain radiographs (X-rays) are routinely performed to rule out calcific tendinitis or glenohumeral arthritis.
- •
Osteopenia is a common radiographic finding.
- •
Magnetic resonance imaging (MRI) is not essential for diagnosis but can rule out confounding pathology.
- •
Hallmark of adhesive capsulitis on MRI is thickening and loss of volume of the axillary pouch.
- •
MRI in stages 1 and 2 demonstrates increased signal in capsule and synovium consistent with hyperemia and synovitis.
- •
MRI in stages 3 and 4 demonstrates low signal capsule with increased capsular thickness in anterior capsule, posterior capsule, and axillary pouch.
- •
One-third of stage 2 adhesive capsulitis patients show some form of supraspinatus pathology on magnetic resonance arthrography. The clinical significance is unknown but should be correlated with physical examination.
- •
Axillary recess thickening up to 1.3 cm or more compared with normal measurement of less than 4 mm
- •
Rotator interval thickening
- •
Glenohumeral ligament thickening
Differential Diagnosis
- •
Shoulder stiffness is a common symptom of many glenohumeral joint conditions. It is critical to distinguish between primary adhesive capsulitis and other disorders because the treatment is time sensitive. The common differential diagnoses are listed in Table 8-3 .
Table 8-3
Possible Differential Diagnoses for Primary Adhesive Capsulitis
Possible Differential Diagnoses
Primary Factor to Supporting Differential vs. Primary Adhesive Capsulitis
Impingement Syndrome (Stage 1)
Positive Neer, Hawkins tests
Shoulder musculature may be tender upon palpation
Cervical spine and neurological pathologies
Character of pain is described as burning/stinging. Pain may follow a radicular pattern
Deficit in strength, sensation, and/or reflexes may exist. Pain may change with motion of cervical spine
Calcific Tendonitis/Bursitis
Rotator cuff tendon(s) present with calcium deposits in radiography
Pain is more sudden in onset. Pain with glenohumeral abduction, may be minimal with rotation in 0° abduction
Acromioclavicular arthritis
Tenderness present upon palpation of AC joint
Positive crossover test
Bicep tendonitis
Tenderness present upon palpation of bicep tendon
Local crepitus with humeral rotation
Severe glenohumeral osteoarthritis
Loss of joint space, osteophytes present on X-ray.
Rotator cuff tendonopathy
Pain present with internal rotation, abduction, and strength testing. MRI (+) for tendonosis.
Treatment
Nonoperative Management
- •
Physical therapy including patient education, manual therapy, therapeutic ROM exercises and periscapular strengthening, neuromuscular re-education and modalities for pain, relaxation, and tissue extensibility (moist heat, cryotherapy, TENS, low power laser)
- •
Oral nonsteroidal antiinflammatory medications (NSAIDs)
- •
Oral corticosteroid
- •
Intraarticular corticosteroid injection
- •
Distension arthrography or hydrodilation
- •
Closed manipulation
Guidelines for Choosing Among Nonoperative Treatments
- •
Optimal treatment options should be selected according to:
- •
The presenting stage of adhesive capsulitis
- •
The degree of irritability
- •
The pain level
- •
The degree of restricted motion
- •
The duration of symptoms and signs
- •
The goals of the patient
- •
- •
A combination of nonsurgical treatments may be ideal.
Surgical Indications
- •
When physical and pharmacological therapies have failed, surgical options should be considered and discussed with the patient.
- •
Failed therapy should be considered when a patient has reached a plateau or progress in increased ROM is extremely slow.
- •
Surgery may be indicated for a painful shoulder that has failed to respond to intraarticular corticosteroids.
- •
Surgery is indicated when the patient is failing to improve with a minimum of 6 months of conservative treatment .
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
- •
Surgical options are dependent on the stage of adhesive capsulitis and other concomitant pathology.
- •
Surgery is elective and based on patient pain, arm dominance, and goals.
- •
Failure to progress with physical therapy goals is a relative indication for surgical treatment.
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Options for surgical treatment include: (1) closed manipulation under anesthesia; (2) manipulation under anesthesia followed by arthroscopy; and (3) arthroscopy, capsular release, and manipulation.
- •
Surgeon preference, degree of osteopenia, and imaging studies guide decision making.
- •
Arthroscopy permits identification and treatment of associated pathology.
- •
Synovectomy is indicated when significant synovitis is present.
- •
Arthroscopic division of the capsule permits a more controlled and precise release than manipulation. The anterior and posterior capsule is released prior to manipulation. The axillary pouch can be released but care must be taken to avoid injury to the axillary nerve.
- •
Performing the manipulation prior to arthroscopy may result in intraarticular bleeding and an obscured view, as well as a risk for fracture.
- •
Patients with idiopathic adhesive capsulitis who have failed arthroscopic and closed manipulation procedures may benefit from an open release.
- •
Patients with secondary adhesive capsulitis may require lysis of adhesions in the subacromial space and release of the coracohumeral ligament.
Evidence
Multiple-Choice Questions
- QUESTION 1.
Which intrinsic factor can lead to primary adhesive capsulitis?
- A.
Calcific tendinitis
- B.
Contracture of RCI
- C.
Subacromial scarring
- D.
None of the above
- A.
- QUESTION 2.
Which stage of adhesive capsulitis is characterized by a Christmas tree (synovium is pedunculated and thickened) synovitis by arthroscopy?
- A.
Stage 1 Preadhesive
- B.
Stage 2 Freezing
- C.
Stage 3 Frozen
- D.
Stage 4 Thawing
- A.
- QUESTION 3.
Stage 3 adhesive capsulitis signs and symptoms include the following:
- A.
Pain at the end range of motion and no improvement under anesthesia
- B.
Profound stiffness and gradual improvement in motion
- C.
Severe night pain and gradual improvement in motion
- D.
Pain referred to deltoid insertion and full motion under anesthesia
- A.
- QUESTION 4.
What nonsurgical treatment for adhesive capsulitis can also be used as a diagnostic tool?
- A.
Oral NSAIDs
- B.
Oral corticosteroids
- C.
Intraarticular steroid injections
- D.
Distention arthrography
- A.
- QUESTION 5.
When is surgery indicated for patients diagnosed with primary adhesive capsulitis?
- A.
As soon as the patient’s physical exam indicates Stage 2 signs and symptoms
- B.
When other physical and pharmacological therapies have failed
- C.
Anytime radiography demonstrates axillary recess thickening greater than 4 mm
- D.
After significant motion loss and stiffness has persisted longer than 4 months
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Pathophysiology )
- QUESTION 2.
Correct answer: B (see Pathophysiology )
- QUESTION 3.
Correct answer: A (see Clinical Presentation )
- QUESTION 4.
Correct answer: C (see Treatment )
- QUESTION 5.
Correct answer: B (see Treatment )
Nonoperative Rehabilitation of Adhesive Capsulitis
- Theresa A. Chiaia, PT, DPT
- Jo A. Hannafin, MD, PhD
- A. Simone Maybin, BS, NSCA-CPT
- Jo A. Hannafin, MD, PhD
- •
Understand the stages of adhesive capsulitis.
- •
The stage of presentation will guide rehabilitation to optimize results.
- •
The stage of presentation will determine the duration of each phase of rehabilitation.
- •
The patient’s response to initial treatment (injection) will determine the duration of each phase.
- •
Achievement of phase-specific goals will determine advancement.
- •
Irritability of the shoulder will guide prescription for range of motion.
- •
Perform reassessment of the patient’s response to treatment to avoid joint inflammation.
- •
Understand the patient’s individual goals will determine discharge planning.
- •
Patient education will help increase compliance with HEP, activity modification, and decrease frustration.
Introduction
- •
The phases of rehabilitation for adhesive capsulitis have typically been written to coincide with the stages of adhesive capsulitis.
- •
These guidelines are written in phases for a patient presenting with stage 2 adhesive capsulitis, because this is when the majority of patients seek treatment.
- •
Stage 1 is characterized by pain, inflammation, and an active synovitis.
- •
Stage 3 is characterized by a stiff shoulder resulting from loss of capsular volume.
- •
Stage 2 is a continuum/transition from stage 1 to 3 and thus has characteristics of both stages.
- •
Five phases of rehabilitation are presented: 1, Symptom Control; 2, Mobility; 3, Optimization of ROM; 4, Strengthening; 5, Functional Activity/Return to Sport.
- •
Regardless of the stage at presentation, the patient will pass through all these phases. The duration of each phase will vary according to the stage of presentation, initial treatment and response, goals of the patient, as well as shoulder dominance.
Phase I (weeks 1 to 4): Symptom Control
Management of Pain and Swelling
- •
NSAIDs
- •
Intraarticular injection
- •
Patient education
- •
Activity modification
- •
Positioning ( Figure 8-1 )
FIGURE 8-1
Positioning of the UE in the plane of the scapula with the elbow higher than shoulder. Also support limitations in IR ROM.
- •
Cryotherapy
- •
TENS
- •
Hydrotherapy
- •
Manual therapy
- •
Moist heat
- •
Low power laser therapy
| PHASE I (weeks 1 to 4) | PHASE II (weeks 5 to 8) | PHASE III (weeks 9 to 16) | PHASE IV (weeks 17 to 22) | PHASE V (weeks 23+) |
|---|---|---|---|---|
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