What is Adhesive Capsulitis?
Adhesive capsulitis, or more commonly known as a frozen shoulder, is a condition that causes stiffness and pain in the shoulder due to inflammation. Diagnosis is guided by the definition provided by the American Academy of Orthopedic Surgeons. This definition focuses on the progressive and all-around limited movement of the shoulder that doesn’t show major signs on x-rays. It’s important to assess any severe loss of passive movement of the shoulder for an accurate diagnosis.
What Causes Adhesive Capsulitis?
Adhesive capsulitis, often referred to as “frozen shoulder”, can generally be split into two categories: primary and secondary.
The cause of primary adhesive capsulitis is usually unknown and it tends to develop gradually. It’s often linked to other health conditions like diabetes, thyroid problems, certain medications, high triglycerides (a type of fat) in the blood, or cervical spondylosis, which is a type of age-related wear and tear of the spine.
Secondary adhesive capsulitis, meanwhile, typically comes about as a result of an injury to the shoulder. Things like tears in the rotator cuff – the group of muscles and tendons surrounding the shoulder joint – broken bones, surgery, or long periods of not moving the shoulder can lead to this condition.
Risk Factors and Frequency for Adhesive Capsulitis
Adhesive capsulitis, also known as frozen shoulder, affects about 2% to 5% of all people. Most of the people diagnosed with this condition are around 55 years old. It slightly affects more women than men, with the ratio being 1.4:1 and it’s often the less frequently used hand that is affected. People who have autoimmune diseases, like thyroid disorders and diabetes, are more likely to develop it. Especially for people with diabetes, adhesive capsulitis treatment may not work as well and the length of their diabetes can affect this.
- Adhesive capsulitis impacts 2% to 5% of people in general.
- People usually get diagnosed around the age 55.
- It affects women slightly more than men (ratio is 1.4:1).
- The hand that is less used is the one often affected.
- Those with autoimmune illnesses such as thyroid diseases and diabetes are more likely to develop it.
- Individuals with diabetes might have less successful treatment outcomes and the time they’ve had diabetes can affect this.
Signs and Symptoms of Adhesive Capsulitis
Adhesive capsulitis, also known as frozen shoulder, is a condition where the shoulder becomes sore and stiff over time. This pain usually starts gradually and gets worse over a period of weeks or months. As the condition progresses, it becomes harder to move the shoulder. The primary way to diagnose it is by observing a reduction in how much you can move your shoulder, both when you try to move it yourself and when someone else tries to move it for you. This limited movement specifically affects raising the arm forward, lifting it sideways, and rotating it both inwards and outwards. In severe cases, the natural movement of the arm when walking can be lost, and there may be visible muscle wasting.
When the sore shoulder is examined, it is typically tender all around the shoulder joint. It’s crucial that the nerves in the arm are still functioning correctly. When resistance is applied as the person tries to move their shoulder, it not only causes pain, but significantly limits the range of motion, mimicking the symptoms of a rotator cuff tear (a shoulder injury). The Apley scratch test is often used to measure internal rotation. This test involves reaching behind your head and then further down your back as far as you can.
Testing for Adhesive Capsulitis
If you have adhesive capsulitis, also known as frozen shoulder, you might notice a decrease in your shoulder’s range of motion and feel pain during a physical examination. This pain can interfere with a thorough exam. You would have noticeably less ability to move your shoulder in various directions compared to your healthy shoulder. The reduced movement typically starts with turning your shoulder outward, then lifting it, rotating it inward, and finally moving it forward.
Some specific tests, like the Neer and Hawkins tests for pinching or impingement, and Speed’s test for issues with the biceps tendon, usually give a positive result. Adhesive capsulitis is mainly diagnosed based on your symptoms and the results of physical exams.
There are no specific lab tests used to diagnose adhesive capsulitis. If your doctor suspects another underlying disease that might be contributing to your symptoms, they might conduct additional lab tests.
Although X-rays or other imaging studies can help in diagnosing adhesive capsulitis, they’re usually not necessary. However, they can be used if there’s a need to check for conditions such as fractures or other possible issues, or if your doctor suspects another condition may be causing your symptoms.
If the cause of your shoulder pain remains unclear, your doctor may use the injection test as a diagnostic tool. This entails injecting a local anesthetic, usually lidocaine, into a part of your shoulder known as the subacromial space. If you have adhesive capsulitis, your range of motion won’t improve, and you’ll still experience discomfort after the injection. But if you have inflammation in the same space (subacromial pathology), like a tendon or bursa problem, you may feel less pain and be able to move your shoulder more freely after the injection.
An MRI may reveal certain changes such as inflammation in the lining of the joint space, thickening of a certain ligament, loss of a specific fat pad, and thickening of the shoulder joint’s capsule. Even though these changes might suggest adhesive capsulitis, none of them are definitive for the condition. The disappearance of a small space in the shoulder joint, when seen on an advanced X-ray process called arthrography, might indicate tightening of the joint capsule.
Treatment Options for Adhesive Capsulitis
Adhesive capsulitis, often known as “frozen shoulder,” is usually a self-limiting condition; it generally gets better on its own within 18 to 30 months. Treatment mostly aims to relieve symptoms, such as pain, and improve the shoulder’s range of motion.
There are several treatment options:
1. NSAIDs: These are medicines that reduce inflammation and can help control the pain in the initial phase of the condition.
2. Physical therapy: Some physical exercises and treatments may help patient recovery, but research on its effectiveness is limited. Gentle movement exercises, stretching and resistance training can improve shoulder functionality and decrease pain. However, too intense exercise can make symptoms worse, so the course of physical therapy should be low-impact and carefully monitored by both the patient and healthcare provider.
3. Oral corticosteroids: This type of medication can provide temporary pain relief and improved function of the shoulder. Still, the benefits usually wear off after a few weeks, and these drugs have potential side effects.
4. Steroid injections into the joint: These can help improve functionality, reduce pain, and enhance mobility of the shoulder. However, the relief is usually short-term, and there can be side effects. The effectiveness tends to be better if given early during the course of the disease, and in some cases, multiple injections may be needed.
5. Hydrodilatation: This treatment involves injecting a mix of saline solution and steroids into the shoulder capsule to help it stretch. It can reduce pain and improve the movement of the shoulder short-term and is seen to be as effective as the joint steroid injection.
There are also more invasive options if the condition doesn’t respond to less aggressive treatments.
– Manipulation under anesthesia: This treatment uses controlled movement of the shoulder under anesthesia. It’s reserved for stubborn cases of frozen shoulder but can carry a risk of fracture.
– Arthroscopic capsular release: This surgical procedure releases tightened structures in the shoulder joint somewhat to improve its range of motion. If the frozen shoulder doesn’t improve with conservative treatments within a year, the patient may need to see an orthopedic surgeon for this procedure.
– Open capsular release: This is a more extensive surgical procedure for releasing the tightened shoulder capsule. It is used in severe cases like after a stroke, head injury, or following another injury or surgery on the joint that has lead to significant hardening of the shoulder tissue.
It’s important to note that any surgical option for treating the adhesive capsulitis should be considered only if other therapeutic options are not effective and the pain continues to prevail.
What else can Adhesive Capsulitis be?
When trying to diagnose a condition known as adhesive capsulitis, or “frozen shoulder,” doctors need to consider a range of other health issues that present similar symptoms. These include:
- Neck issues caused by pinched nerves (Cervical radiculopathy)
- An inflammation of the joint connecting the collarbone to the shoulder blade (Acromioclavicular joint arthrosis)
- An injury to the main tendon in the upper arm (Bicep tendinopathy)
- Arthritis in the main shoulder joint (Glenohumeral arthritis)
- A broken bone (Fracture)
- An inflammation condition in which calcium deposits form on the tendons (Calcifying tendinitis/synovitis)
- A cancerous tumor (Malignancy)
- A condition where the muscles and tendons of the shoulder become squeezed (Rotator cuff impingement)
- An inflammatory disorder causing muscle pain and stiffness (Polymyalgia rheumatica)
- A related condition also involving the squeezing of muscles and tendons (Shoulder impingement syndrome)
Therefore, the doctor must perform certain tests and ask careful questions to distinguish between these possibilities and reach the correct diagnosis.
Possible Complications When Diagnosed with Adhesive Capsulitis
Here are some potential problems that can occur with the shoulder:
- Leftover shoulder pain and/or stiffness
- Fracture of the humerus (the upper arm bone)
- Damage or breakage of the biceps and subscapularis tendons (tissues connecting muscles to bones)
- Tears in the labrum (a type of cartilage in the shoulder)
- Dislocation of the glenohumeral joint (the ball and socket joint in the shoulder)
- Tear in the rotator cuff (a group of muscles and tendons providing shoulder stability)
Recovery from Adhesive Capsulitis
For patients undergoing treatment for adhesive capsulitis, also known as frozen shoulder, joining a formal exercise program is typically recommended.
The goal of rehabilitation for frozen shoulder is to manage pain, either maintain or improve flexibility and movement (range of motion), and help the patient return to their regular activities. The exact kind of therapy the patient receives depends on various factors, such as the stage of their frozen shoulder, their age, how active they are, and any other health issues they might have. A set of exercises known as proprioceptive neuromuscular facilitation (PNF) has been shown to effectively increase range of motion and lessen pain.
There are also other techniques to reduce pain such as ultrasound and electrical stimulation, though evidence on their effectiveness is not consistent. Similarly, manual therapy methods need more research to establish standard guidelines for their frequency, dosage, and duration. It’s critical for therapists and doctors to work closely together during this process, since orthopedic doctors might have specific sets of rehabilitation steps for therapists to follow.
Preventing Adhesive Capsulitis
Teaching patients about adhesive capsulitis, also known as frozen shoulder, is a crucial part of its treatment. Here are some important points that patients should understand:
1. What is a frozen shoulder? In simple terms, a frozen shoulder is a medical condition that causes stiffness and pain in the shoulder joint. It will heal on its own over time.
2. How long does it last? Frozen shoulder usually goes through three stages: a painful period, a ‘frozen’ or sticky stage, and a stage where the symptoms gradually decrease. Healing can take several months to years.
3. How can exercises help? Regular, gentle movements can help increase shoulder flexibility and prevent it from becoming stiffer. Physical therapy can play a significant role in improving movement.
Realistic expectations: Patients should be aware that recovery from a frozen shoulder requires patience and time.
When to get help: If patients experience severe symptoms, if their condition gets worse, or if they start to feel weak or numb in the arm, they should seek medical help immediately.
