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Rehabilitation Medicine

Adhesive capsulitis

Adhesive capsulitis, most commonly referred to as frozen shoulder (FS), is an idiopathic disease with 2 principal characteristics: pain and contracture.
Shoulder pain associated with FS is progressive and initially felt mostly at night or when the shoulder is moved close to the end of its range of motion (ROM). It can be caused by certain combined movements of the shoulder, such as abduction and external rotation (eg, grooming one's hair, reaching for a seatbelt overhead) or extension and internal rotation (eg, reaching for a back pocket or bra strap). The pain usually progresses to constant pain at rest that is aggravated by all movements of the shoulder and that may be worsened by repetitive movements of the involved upper extremity, psychological stress, exposure to cold or vibration, and changes in the weather. In approximately 90% of patients with FS, this pain usually lasts 1-2 years before subsiding.
The second principal characteristic of FS is progressive loss of passive ROM (PROM) and active ROM (AROM) of the glenohumeral joint in a capsular pattern. That is, the movements are usually restricted to a characteristic pattern, with proportionally greater passive loss of external rotation than of abduction and internal rotation.
Most authors do not describe clinically significant capsular adhesions as a predominant finding in the chronic phase of this condition. Instead, pathologic data confirm an active process of hyperplastic fibroplasia and excessive type III collagen secretion that lead to soft-tissue contractures of the aforementioned structures (ie, the coracohumeral ligament, soft tissues of rotator interval, the subscapularis muscle, the subacromial bursae). However, these findings were observed in surgical patients who had severe and late-phase disease and cannot be applied to early phases of the disease.
Shoulder pain is the third most common cause of musculoskeletal disability after low back pain (LBP) and neck pain. The prevalence of FS in the general population is reported to be 2%, with an 11% prevalence in unselected individuals with diabetes. For patients with type I diabetes, the risk of developing FS in their lifetime is approximately 40%.
FS may affect both shoulders, either simultaneously or sequentially, in as many as 16% of patients. The frequency of bilateral FS is higher in subjects with diabetes than in those without diabetes. In 14% of patients, while FS still is active in the initial shoulder, the contralateral shoulder also becomes affected. Contralateral FS usually occurs within 5 years of disease onset. A relapse of FS in the same shoulder is unusual.
FS most frequently occurs in subjects with hyperthyroidism and hypertriglyceridemia. Although various authors report that heart disease, tuberculosis, and many other medical conditions are associated with FS, these associations are largely anecdotal and are not supported in proper, case-controlled studies.
Most survivors of cerebral vascular accidents (CVAs) that cause hemiplegia develop painful stiffening of their shoulders. However, the painful hemiplegic shoulder has distinct characteristics, which are not discussed in this article.
FS will undoubtedly become increasingly common as the baby-boom generation ages, because this condition most frequently occurs in the fifth and sixth decades of life. Patients who present with an idiopathic FS when they are younger than 40 years should definitely be examined to rule out occult diabetes, hyperthyroidism, hypertriglyceridemia, or concomitant neurologic or systemic rheumatologic disorder affecting the upper extremity.
Clinical phases
The following 3 clinical phases typically characterize FS:
•Phase 1 - The painful phase; the patient describes an insidious onset of predominantly nocturnal pain, usually without a precipitating factor. The pain is not related to activity, although the farthest ROM can increase the pain. As the disease progresses, patients have pain at rest. In this phase, which lasts 2-9 months, ROM is not restricted, and the diagnosis may remain unclear. 
•Phase 2 - The frozen, or adhesive, phase; the pain from phase 1 can persist, although it may decrease. Progressive limitation in ROM occurs in a capsular pattern (that is, in all directions). Normal daily activities can be severely affected. Hallmarks of this phase are an inability to move at great amplitude and an inability to move on the affected side. Diagnosis is easier in this phase than in phase 1. Although phase 2 is reported to last 3-9 months, it can persist longer than this.
•Phase 3 - The thawing, or regressive, phase; pain progressively decreases, and limitations in ROM progressively increase over 12-24 months. Although approximately 40% of patients have slight, persistent limitations in ROM, only 10% have clinically significant long-term functional limitations. 
FS can result from clinically significant trauma to the shoulder, cervical radiculopathy, pathology of the brachial plexus, any neurologic insult affecting shoulder function or innervation, or an episode of rotator cuff tendonitis. However, FS usually occurs without any clear precipitating factors. Most patients with FS have no notable history of trauma. Hence, the clinician must remember that this is an idiopathic disease in which the loss of ROM results from a dystrophic pain syndrome combined with contracture caused by an active process resembling fibromatosis.
Although patients often try to recall minor trauma associated with the onset of their shoulder symptoms, careful history taking on the part of the examiner often reveals subtle symptoms, such as night pain or pain and stiffness at the end of ROM, that predated the episode of minor trauma. In most cases, the minor trauma simply makes the patient conscious of the insidious, underlying disease process.
Patients with FS typically describe a progressive onset of pain over several weeks. Patients usually report that the initial pain was night pain or pain associated with involved movements of the shoulder (eg, combing one's hair, reaching overhead for a seat belt, reaching for one's back pocket). Combing one's hair and reaching overhead for a seat belt require a combined motion of abduction and external rotation, and reaching for one's back pocket requires extension and internal rotation of the shoulder. These combined movements tend to stretch the anterior and posterior glenohumeral capsule, respectively.
The pain of FS then progresses to a constant pain at rest that is often aggravated by any movement of the shoulder, psychological stress, exposure to cold or vibration, and changes in the weather. Patients report worsening of the pain after they engage in activities that require repetitive movements of the affected shoulder.
In about 90% of patients, the pain associated with this condition usually lasts 1-2 years before subsiding. The pain is a prominent feature of the initial phase and of the second (frozen) phase of the disease. During the thawing phase, the pain usually is less intense than it is in the other phases. It is usually felt only if the patient is moving at the end of his/her ROM (particularly in positions of subacromial impingement), if the patient performs repetitive movements of the shoulder, or if the patient is exposed to other important ergonomic stresses of the shoulder.
In the early phase of FS, the only physical finding may be pain produced at the end of ROMs in the glenohumeral joint, particularly those that stretch the capsule, such as combined abduction and external rotation (such as combing one's hair) or combined extension and internal rotation (such as reaching to scratch one's midback). During the initial, painful stage, FS may not be distinguishable from an inflammatory synovitis affecting the glenohumeral joint or from a painful episode of rotator cuff tendinopathy. In the second, or freezing, stage of the disease, contracture of the glenohumeral joint becomes readily apparent. This stage may occur only several months after the onset of symptoms.
As the condition progresses, the clinician should observe progressive limitation of the PROM, characterized by a painful capsular end-feel. The motion affected first and most severely is external rotation, followed by abduction, internal rotation, and flexion. Extension and horizontal adduction tend to be least affected. PROM of the glenohumeral joint progressively worsens over several months and may result in a loss of up to 80% of the normal movement of glenohumeral joint.
In severe cases, evaluation of AROM may show an inverted scapulothoracic motion (that is, motion of the scapula on the thorax). For example, the scapulothoracic joint initiates abduction (followed by the glenohumeral joint) to compensate for the loss of ROM in the glenohumeral joint.
On occasion, a sizable calcification of the rotator cuff in its resorptive phase may cause an acute tendinobursitis that may mimic FS. This type of acute tendinobursitis may be extremely painful, and it may result in an antalgic phenomenon, causing a loss of PROM. The acute and rapidly progressive onset of tendinobursitis over a few hours or days differentiates it from the relatively progressive onset of FS, which occurs over weeks. Another mimic of FS is severe synovitis or arthritis of the glenohumeral joint caused by an underlying primary rheumatologic inflammatory, degenerative, septic, or metastatic process.
Most patients with a painful FS have pain during resisted contraction of all of the rotator cuff tendons, during specific maneuvers designed to detect subacromial impingement (for example, the Hawkins, Neer, and Yocum maneuvers), and during maneuvers designed to detect tendinopathy of the long portion of the biceps (such as the Yergason and Speeds maneuvers). This phenomenon results because the pain generators in FS may include all of the extra-articular and intra-articular soft tissues of the glenohumeral joint and humeroscapular-motion interface (eg, subacromial bursa, rotator cuff, biceps tendon). (See Mechanics of Glenohumeral Arthritis, on the University of Washington School of Medicine Web site.)
In the presence of a clinically significant loss of PROM of the glenohumeral joint in the previously described capsular pattern, the clinician should probably be content with retaining the diagnosis of FS while de-emphasizing the aforementioned maneuvers designed to diagnose other specific, painful soft-tissue disorders affecting the shoulder.
Early authors pointed to chronic inflammation as the cause of the fibrosis in FS, but objective findings have not supported this suggestion. The absence of crystals, synovial effusion, systemic symptoms, prodromal illness, and serologic markers of autoimmune or reactive arthropathic disease has limited possible theories of an inflammatory process secondary to crystalline, inflammatory, viral, or autoimmune disease.
FS remains a largely idiopathic disorder. The conditions most commonly associated with idiopathic FS are diabetes, hyperthyroidism, hypertriglyceridemia, CVA with upper-extremity paresis, brachial plexus injury, cervical spinal cord injury, and Parkinson disease. The performance of repetitive movements of the upper extremities also is associated with FS.
Anecdotal reports of patients developing FS after a coronary event or following open heart surgery are frequently found in the literature. However, the authors know of no prospective case-control study that has been conducted to confirm this supposition.
Patients who have active glenohumeral synovitis in relation to a systemic inflammatory rheumatologic disorder may develop FS as a complication of this condition. Patients who have undergone surgery to the shoulder area, with postoperative immobilization or with clinically significant pain that causes them to immobilize their shoulder, also are predisposed to develop FS.
Differential Diagnoses
•Biceps Rupture
•Biceps Tendinopathy
•Brachial Neuritis
•Cervical Disc Disease
•Cervical Myofascial Pain
•Cervical Spondylosis
•Cervical Sprain and Strain
•Heterotopic Ossification
•Neoplastic Brachial Plexopathy
•Parkinson Disease
•Physical Medicine and Rehabilitation for Complex Regional Pain Syndromes
•Rheumatoid Arthritis
•Rotator Cuff Disease
•Shoulder Pain in Hemiplegia
•Spina Bifida
•Thoracic Outlet Syndrome
•Traumatic Brachial Plexopathy

[Update: 2020 - 01 - 03 ]