Diagnosis Adhesive Capsulitis: A Comprehensive Guide for Automotive Repair Professionals

Introduction

Adhesive capsulitis, commonly known as frozen shoulder, is a prevalent inflammatory condition marked by significant shoulder stiffness, pain, and a notable reduction in passive range of motion (ROM). This condition can lead to long-term disability in 10% to 20% of patients, with persistent symptoms reported in 30% to 60% of cases. Adhesive capsulitis affects approximately 2% to 5% of the general population, with the typical age of onset around 55 years. It exhibits a slight female predominance (1.4:1). While the precise cause of adhesive capsulitis remains unclear, understanding its diagnosis and management is crucial. This article provides an in-depth review of the evaluation and management of adhesive capsulitis, emphasizing its diagnosis and the importance of a multidisciplinary approach in patient care.

Etiology of Adhesive Capsulitis

Adhesive capsulitis is broadly categorized into primary and secondary types, each with distinct underlying factors.

Primary Adhesive Capsulitis: This form is typically idiopathic, meaning it arises spontaneously with no identifiable underlying cause. Its onset is gradual, and it is often associated with systemic conditions such as:

• Diabetes mellitus
• Thyroid disease
• Certain medications
• Hypertriglyceridemia
• Cervical spondylosis

Secondary Adhesive Capsulitis: This type usually develops as a consequence of a known factor affecting the shoulder. Common causes include:

• Shoulder trauma
• Rotator cuff tears
• Fractures
• Post-surgical stiffness
• Prolonged immobilization of the shoulder

Epidemiology of Adhesive Capsulitis

Adhesive capsulitis is a relatively common condition, affecting 2% to 5% of the general population. The average age of onset is around 55 years, and it is slightly more prevalent in women (female-to-male ratio of 1.4:1). The non-dominant shoulder is more frequently affected. Individuals with autoimmune conditions, particularly thyroid disorders and diabetes mellitus, have a higher predisposition to developing adhesive capsulitis. Furthermore, in diabetic patients, the duration of diabetes can influence treatment outcomes, often leading to less favorable results.

Pathophysiology of Adhesive Capsulitis

The exact mechanisms driving adhesive capsulitis are still not fully understood. The prevailing theory suggests that the condition begins with inflammation within the shoulder joint capsule and synovial fluid. This initial inflammatory phase is followed by reactive fibrosis and the formation of adhesions within the synovial lining. The early inflammation is responsible for the pain experienced, while the subsequent capsular fibrosis and adhesions lead to the characteristic restricted range of motion.

Histopathology of Adhesive Capsulitis

The histopathological characteristics of adhesive capsulitis are dynamic and vary depending on the stage of the condition. It is recognized as a process involving both inflammation and fibrosis, progressing through distinct phases:

• Inflammatory Phase: This initial phase is marked by inflammation within the joint capsule.
• Fibrotic Phase: Characterized by increasing stiffness and a progressive limitation in range of motion (ROM) due to fibrosis and adhesion formation.
• Thawing Phase: Also known as the regression phase, this stage is characterized by a gradual spontaneous improvement in shoulder mobility.

The duration of each phase is variable among individuals. Arthroscopic studies provide visual evidence of these pathological changes, revealing:

• Subacromial Fibrosis: Fibrous tissue and adhesions in the subacromial space, contributing to restricted movement and potential impingement of shoulder structures.
• Proliferative Synovitis: Inflammation and excessive proliferation of the synovium lining the joint capsule, leading to thickening of the synovial tissue.
• Capsular Thickening: Thickening and fibrosis of the joint capsule itself, resulting in stiffness and reduced ROM.

These arthroscopic findings are consistent with the diagnosis of adhesive capsulitis and provide direct visualization of the pathological changes within the affected joint.

History and Physical Examination for Diagnosis Adhesive Capsulitis

Patients presenting with adhesive capsulitis typically report a gradual onset of shoulder pain that intensifies over weeks to months. This pain is subsequently followed by a significant restriction in shoulder movement. A hallmark clinical sign for Diagnosis Adhesive Capsulitis is a noticeable reduction in both active and passive ROM, particularly in forward flexion, abduction, external rotation, and internal rotation. In severe cases, patients may lose the natural arm swing during walking and exhibit muscle atrophy around the shoulder.

Physical examination often reveals:

• Diffuse tenderness upon palpation around the shoulder joint.
• Intact distal neurological function.
• Pain and marked limitation of motion with resisted shoulder movements, sometimes mimicking rotator cuff pathology.
• Limited internal rotation, often assessed using the Apley scratch test.

Evaluation and Diagnosis Adhesive Capsulitis

Diagnosis adhesive capsulitis is primarily clinical, relying heavily on history and physical examination findings. During physical evaluation, key findings include:

• Decreased Glenohumeral ROM: A significant reduction in shoulder joint range of motion is a primary indicator.
• Pain with ROM Testing: Pain is typically elicited during attempts to move the shoulder, further limiting a complete examination.
• Pattern of ROM Loss: Characteristically, the loss of ROM follows a specific pattern, with external rotation being affected first, followed by abduction, internal rotation, and finally forward flexion.
• Comparison to Unaffected Side: A significant decrease in active and passive ROM in at least two planes of motion compared to the unaffected shoulder is a strong diagnostic indicator.

Special orthopedic tests, such as the Neer and Hawkins tests (for impingement) and Speed’s test (for biceps tendinopathy), may be positive but are not specific to adhesive capsulitis and help rule out other conditions.

Diagnostic Injection Test: In cases where the diagnosis is uncertain, an injection test can be valuable. This involves injecting a local anesthetic, typically 5 ml of 1% lidocaine, into the subacromial space.

• Adhesive Capsulitis Indication: If ROM limitations and pain persist even after the injection, it supports the diagnosis of adhesive capsulitis.
• Subacromial Pathology Indication: In contrast, patients with subacromial conditions like rotator cuff tendinopathy or subacromial bursitis often experience pain relief and improved ROM following the injection.

Imaging Studies: While diagnosis adhesive capsulitis is mainly clinical, imaging may be considered in specific situations:

• Shoulder X-ray: May be used to rule out alternative diagnoses such as fractures or other bony pathologies.
• Magnetic Resonance Imaging (MRI): MRI findings suggestive of adhesive capsulitis include:
  • Rotator interval synovitis
  • Hypertrophy of the coracohumeral ligament
  • Loss of the subcoracoid fat triangle
  • Thickening of the glenohumeral joint capsule, particularly in the axillary pouch.
    While these findings are characteristic, they are not pathognomonic for adhesive capsulitis.
• Arthrography: The disappearance of the typical axillary recess on arthrography can suggest joint capsule contracture, supporting the diagnosis.

Laboratory Tests: Typically, no specific laboratory tests are required for diagnosis adhesive capsulitis. However, if there is suspicion of an underlying systemic disease contributing to the condition, further laboratory investigations may be warranted to identify and address the underlying cause.

Treatment and Management of Adhesive Capsulitis

Adhesive capsulitis is often a self-limiting condition, with spontaneous recovery occurring in many cases within 18 to 30 months. Treatment strategies primarily focus on symptomatic relief and improving shoulder ROM. Available treatment options include:

• Physical Therapy: While evidence supporting its effectiveness is limited, physical therapy can be beneficial, particularly during the recovery phase.

  • Gentle ROM exercises
  • Stretching techniques
  • Graded resistance training
    These interventions may help reduce pain and improve shoulder function. However, it’s crucial to avoid aggressive rehabilitation, as it may exacerbate symptoms. A cautious and closely monitored approach to physical therapy is recommended.

• Intra-articular Steroid Injections: Corticosteroid injections have been shown to be effective in:

  • Improving shoulder function
  • Reducing pain
  • Increasing ROM
    However, the effects of steroid injections are often temporary. Potential side effects must be considered, and early administration in the disease course may enhance outcomes. Multiple injections may be considered for continued symptomatic relief.

• Manipulation Under Anesthesia (MUA): Reserved for refractory cases that do not respond to conservative treatments. MUA carries a risk of humerus fracture. The procedure involves gently manipulating the shoulder joint in various planes of motion under anesthesia. If significant resistance is encountered, force should not be applied. An injection of triamcinolone mixed with bupivacaine may be administered during the procedure to reduce post-manipulation inflammation.

• Arthroscopic Capsular Release: This surgical option is also reserved for refractory cases. Referral to an orthopedic surgeon is recommended if symptoms persist despite conservative management for 10 to 12 months. The procedure involves arthroscopically releasing contracted joint capsule structures (rotator cuff interval, coracohumeral ligament, glenohumeral ligaments, and anterior/posterior capsule) to improve ROM. Inferior capsule release is performed cautiously due to the proximity of the axillary nerve. Post-release, the subacromial space is inspected and debrided if necessary. Intra-articular injection of triamcinolone and bupivacaine is typically administered post-procedure, followed by early passive and active ROM exercises. The literature lacks conclusive evidence comparing the clinical efficacy of arthroscopic capsular release to manipulation under anesthesia.

• Open Capsular Release: This more invasive procedure is considered for specific patient populations, including those with:

  • Stroke or head injuries
  • Post-traumatic or post-surgical adhesive capsulitis with significant adhesions that limit arthroscopic access.
    Open release involves a larger incision to directly access and release the thickened joint capsule. It is associated with higher morbidity compared to arthroscopic release.

Surgical Indications:

• Failure of prednisone or NSAIDs trial.
• Lack of response to glenohumeral or subacromial injections.
• No improvement with physical therapy.

Surgical Contraindications:

• Inadequate trial of steroids or NSAIDs.
• Absence of conservative therapy attempts.
• Acute infection.
• Concomitant malignancy in the shoulder region.
• Neurological deficit or nerve pain originating from the cervical spine.

Differential Diagnosis for Adhesive Capsulitis

When considering diagnosis adhesive capsulitis, it is essential to differentiate it from other conditions presenting with shoulder pain and stiffness:

• Cervical radiculopathy
• Acromioclavicular joint arthrosis
• Biceps tendinopathy
• Glenohumeral arthritis
• Fracture
• Calcifying tendinitis/synovitis
• Malignancy
• Rotator cuff impingement
• Polymyalgia rheumatica
• Shoulder impingement syndrome

Staging of Adhesive Capsulitis

Adhesive capsulitis typically progresses through three clinical stages:

• Phase 1: Painful Phase: Characterized by diffuse and often disabling shoulder pain, typically worse at night, accompanied by increasing stiffness. This phase can last from 2 to 9 months.
• Phase 2: Frozen (Adhesive) Phase: Marked by progressive ROM limitation in all shoulder planes. Pain intensity gradually subsides during this phase, which typically lasts 4 to 12 months.
• Phase 3: Thawing (Regression) Phase: Characterized by a gradual spontaneous return of shoulder ROM. Full ROM recovery may take 12 to 24 months.

Complications of Adhesive Capsulitis

Potential complications associated with adhesive capsulitis and its treatment include:

• Residual shoulder pain and/or stiffness
• Humeral fracture (particularly with MUA)
• Rupture of the biceps and subscapularis tendons
• Labral tears
• Glenohumeral joint dislocation
• Rotator cuff tear

Postoperative and Rehabilitation Care

Following surgical interventions, enrollment in a formal exercise program is a crucial component of adhesive capsulitis treatment.

Rehabilitation: Rehabilitation aims to:

• Manage pain
• Maintain or improve ROM
• Facilitate return to functional activities

The specific rehabilitation approach is tailored to the patient’s stage of condition, age, activity level, and comorbidities. Proprioceptive neuromuscular facilitation (PNF) exercises have shown effectiveness in improving ROM and reducing pain. Other pain management techniques such as ultrasound and electrical stimulation are commonly used but lack robust evidence to support their consistent efficacy. Manual therapy techniques also require further research to standardize protocols. Close collaboration between therapists and physicians is essential, as orthopedic physicians often have specific rehabilitation protocols.

Consultations for Adhesive Capsulitis

Management of adhesive capsulitis may involve a multidisciplinary team of healthcare professionals:

• Primary Care Physician: Often the initial point of contact for evaluation and initial management.
• Physical Therapist: Plays a critical role in pain reduction, mobility restoration, and functional optimization.
• Occupational Therapist: May be involved to provide strategies and assistive devices to adapt and improve performance of daily tasks.
• Orthopedic Specialist, Pain Management Specialist, or Rheumatologist: Consultation with specialists may be necessary for severe or non-responsive cases.

Deterrence and Patient Education

Patient education is a vital aspect of adhesive capsulitis management. Key points to include in patient education are:

1. Explanation of the Condition: Clearly describe adhesive capsulitis, emphasizing its self-limiting nature and the characteristic stiffness and pain.
2. Natural Course and Timeline: Explain the three phases (painful, frozen, thawing) and the prolonged recovery timeline (months to years).
3. Range of Motion Exercises: Educate on the importance of regular, gentle exercises to improve mobility and prevent further stiffness, ideally under the guidance of a physical therapist.
4. Patience and Time Frame: Set realistic expectations regarding the lengthy recovery process.
5. When to Seek Medical Help: Advise patients to seek medical attention for severe or worsening symptoms, new weakness, or numbness in the arm.

Pearls and Other Important Considerations

• Adhesive capsulitis is an inflammatory condition causing shoulder stiffness and pain.
• Significant loss of passive ROM is a key diagnostic feature.
• The pathophysiology is not fully understood, but inflammation within the joint capsule is a primary factor.
• Routine laboratory testing is not indicated unless underlying systemic disease is suspected.
• Diagnostic imaging is not routinely necessary but may be used to rule out other conditions.
• Adhesive capsulitis is often self-limiting, with a favorable prognosis, especially with early diagnosis and appropriate management including physical therapy.

Enhancing Healthcare Team Outcomes

Effective management of adhesive capsulitis requires a collaborative healthcare team approach. Primary care providers, orthopedic specialists, specialty care nurses, and physical therapists all play crucial roles. Early diagnosis, effective communication, accurate record-keeping, and timely referrals are essential for optimizing patient outcomes. Teamwork and collaboration have been shown to improve outcomes in managing adhesive capsulitis. Despite conservative management, long-term disability and persistent symptoms can occur in a significant proportion of patients.

Review Questions

(The original article includes review questions and references here.)

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Disclosures

Disclosure: John St Angelo declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Taqi declares no relevant financial relationships with ineligible companies.

Disclosure: Sarah Fabiano declares no relevant financial relationships with ineligible companies.