Article: Treatment of adhesive capsulitis: a review (G. D’Orsi et al., Muscles, Ligaments and Tendons Journal 2012; 2(2): 70-78).

Written by: Jody Murray BPHE/BSc, MD, CCFP

Definition:

A gradual and painful loss of both active and passive range of motion, in all planes of motion, especially external rotation. Progressive fibrosis and contracture of the glenohumeral joint capsule. Pain occurs near the deltoid insertion. Xray is normal. Occurs in 2-5% of the population.

More frequently occurs in women, aged 40-60 years. Occasionally can be bilateral in 20-30% of cases.

Commonly associated conditions are diabetes, thyroid dysfunctions, dupuytren contracture, cardiorespiratory and autoimmune conditions. Predisposing conditions like prolonged shoulder immobilization secondary to trauma or surgery are seen.

Classification – Primary vs Secondary:

Primary – Adhesive capsulitis (AC) without any known precipitating cause, self limited and resolves spontaneously by 2-4 years.

Secondary – AC with another cause for shoulder stiffness like calcific tendinopathy, rotator cuff tears, arthritis of the glenohumeral joint or acromioclavicular joint, previous shoulder trauma or surgery.

Stages of the condition:

Stage 1:

Painful phase: ache radiating to deltoid, gradual onset of symptoms, mild limitation in range of motion (ROM)

Length of symptoms: < 3 mos

Treatment options: NSAIDS (no more than 4 weeks), intra-articular steroid injection, intra-articular sodium hyaluronate injection, stretching and exercise program working within the limits of pain

Stage 2:

Freezing stage: Nocturnal pain, worse when lying on the affected side, significant loss of active and passive ROM

Treatment options: prevent and reduce the formation of adhesions with exercise program and mobilization techniques

Length of symptoms: 3-9mos

Stage 3:

Frozen stage: shoulder stiffness is predominant and pain may still be present at end of range of motion or at night

Treatment options: correct compensatory movements and restore a proper dynamic shoulder joint via physiotherapy, care needs to be taken to control pain during this phase

Length of symptoms: 9-14mos

Stage 4:

Thawing stage: minimal pain and a gradual improvement in ROM due to capsular remodeling

Length of symptoms: 15-24mos

Treatment options: strengthening program of scapular muscles and rotator cuff muscles, proprioceptive retraining

Consider surgical options (arthroscopic capsulotomy) for patients refractory after 6 months of conservative therapy.

Other treatment options commonly discussed

Suprascapular nerve block – xylocaine/bupivacaine injected blind or electromyographically or ultrasound guided; appeared to be better than placebo for pain relief but no better then intraarticular steroid injection

Arthrographic distension – Injection of a saline solution or steroid into the shoulder to break up the adhesions; appears to be better than placebo but no difference when compared to a steroid injection

Mobilization under anesthesia – no evidence that it was better then a home exercise program and with increased risk of complications