Abstract
Adhesive capsulitis, or frozen shoulder, is a common orthopaedic disorder characterized by shoulder pain followed by progressive loss of both active and passive range of motion (ROM) of the glenohumeral joint. Up to 5% of the general population may be affected by a frozen shoulder, with a strong female predisposition and a far higher percentage in diabetics. Although the pathophysiology is not fully understood, it appears that inflammation of the glenohumeral joint leads to fibrosis of the synovium with resultant pain and ROM loss. Management focuses first on pain relief and then on the aggressive restoration of shoulder ROM via physical therapy, local modalities, and injections. Most patients do well with a conservative management approach, with only a very small percentage requiring surgery. Spontaneous resolution may occur but can take 2 years or longer.
Key Concepts
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Progressive loss of active and passive glenohumeral motion resulting from contraction of the glenohumeral synovial capsule ( Fig. 36.1 )
Fig 36.1
Fibrosis and contraction of the glenohumeral synovium.
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Commonly referred to as “frozen shoulder,” or arthrofibrosis
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Pathophysiology is poorly understood but likely inflammatory. Recent data have implicated cytokines and matrix metalloproteases in the development of pathologic changes in the synovium.
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“Primary” adhesive capsulitis is idiopathic. Insidious onset of shoulder pain leads to avoidance of use and a slowly progressive decline in shoulder motion and functional ability.
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“Secondary” adhesive capsulitis may be associated with a number of underlying conditions or genetic predispositions ( Box 36.1 ).
Box 36.1
Risk Factors for Adhesive Capsulitis
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Female sex
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Age over 40 years
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Preceding trauma, particularly periarticular fracture dislocation of glenohumeral joint or other severe articular trauma
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Prolonged shoulder immobilization
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White patients
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Family history of adhesive capsulitis
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HLA-B27 positivity
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Diabetes
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Thyroid disease
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Autoimmune diseases (rheumatoid arthritis, scleroderma)
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Coronary artery disease
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Cerebrovascular disease
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Dupuytren disease
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Chronic lung disease or lung cancer
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Cervical radicular disease
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Prevalence in the general population is 3-5%; as high as 20% in diabetics.
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70% of patients are female; there is a 20-30% incidence of future involvement of the opposite shoulder.
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Peak incidence between ages 40 and 59
History
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Stages 1 and 2 (“Painful freezing phase”)
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Symptoms present for weeks up to 9 months.
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Aching shoulder pain at rest and sharp at the extremes of range of motion (ROM). Pain generally precedes ROM loss.
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External rotation is often lost first, with progressive loss of motion in internal rotation, forward flexion, and abduction thereafter.
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Majority of motion loss in first 3 months is secondary to painful synovitis; beyond 3 months is primarily due to capsular contraction and loss of capsular volume.
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Histologically, inflammatory cell infiltration of the synovium followed by synovial proliferation
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Stage 3 (“Adhesive phase”)
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Symptoms present for 9 to 14 months.
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Prominent stiffening of the shoulder with significant loss of ROM.
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Patients often report a history of an extremely painful phase that has resolved, resulting in a relatively pain-free but stiff shoulder.
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Histologically, dense collagenous tissue within the joint capsule
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Stage 4 (“Resolution or thawing phase”)
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Occurs spontaneously, generally after a minimum of 2 years
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Characterized by slow, steady recovery of ROM resulting from capsular remodeling in response to use of the arm and shoulder
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