View source for Medicine:Adhesive capsulitis of shoulder

{{short description|Human disease:  painful and disabling disorder of unclear cause in which the shoulder capsule}}
{{Infobox medical condition (new)
| name            = Adhesive capsulitis of the shoulder
| synonyms        = Frozen shoulder
| image           = Gray327.png
| caption         = The right shoulder & glenohumeral joint.
| pronounce       = 
| field           = Orthopedics
| symptoms        = Pain, stiffness, restricted movement<ref name = "Kelley_2013">{{cite journal | vauthors = Kelley MJ, Shaffer MA, Kuhn JE, Michener LA, Seitz AL, Uhl TL, Godges JJ, McClure PW | display-authors = 6 | title = Shoulder pain and mobility deficits: adhesive capsulitis | journal = The Journal of Orthopaedic and Sports Physical Therapy | volume = 43 | issue = 5 | pages = A1-31 | date = May 2013 | pmid = 23636125 | doi = 10.2519/jospt.2013.0302 }}</ref>
| complications   = 
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| causes          = 
| risks           = 
| diagnosis       = 
| differential    = 
| prevention      = 
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'''Adhesive capsulitis''', also known as a '''frozen shoulder''', is a painful and disabling disorder of unclear cause in which the shoulder [[Biology:Joint capsule|capsule]], the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, greatly restricting motion and causing pain. Pain is usually constant, worse at night, and with cold weather. Certain movements or bumps can provoke episodes of increased pain. People who have adhesive capsulitis usually experience pain and sleep deprivation for prolonged periods due to pain that gets worse when lying still and restricted movement. The condition can lead to depression, problems in the neck and back, and weight loss due to long-term lack of deep sleep. People who have adhesive capsulitis may have difficulty concentrating, working, or performing daily life activities for extended periods of time. The condition tends to be self-limiting and usually resolves over time without surgery. Most people regain about 90% of shoulder motion over time.

The condition is thought to be caused by injury or trauma to the area and may have an [[Medicine:Autoimmunity|autoimmune]] component. Risk factors for frozen shoulder include tonic seizures, [[Medicine:Diabetes mellitus|diabetes mellitus]], [[Medicine:Stroke|stroke]], accidents, [[Medicine:Lung disease|lung disease]], connective tissue diseases, thyroid disease, and heart disease. It is more prevalent in people 40–65 years of age, and in females.<ref name = "Kelley_2013" /> 

Treatment may be painful and taxing and consists of [[Medicine:Physical therapy|physical therapy]], [[Medicine:Occupational therapy|occupational therapy]], medication, [[Medicine:Massage|massage]] therapy, [[Medicine:Hydrodilatation|hydrodilatation]] or surgery.  A [[Medicine:Physician|physician]] may also perform manipulation under [[Medicine:Anesthesia|anesthesia]], which breaks up the [[Medicine:Adhesion|adhesion]]s and [[Medicine:Granulation tissue|scar tissue]] in the joint to help restore some range of motion. Alternative treatments exist such as the Trigenics OAT Procedure, ART, and the OTZ method. But these can vary in efficacy depending on the type and severity of the frozen shoulder. Pain and inflammation can be controlled with pain medications such as NSAIDs. Steroid injection alone is only of short term benefit in improving pain.<ref>{{cite journal | vauthors = Uppal HS, Evans JP, Smith C | title = Frozen shoulder: A systematic review of therapeutic options | journal = World Journal of Orthopedics | volume = 6 | issue = 2 | pages = 263–8 | date = March 2015 | pmid = 25793166 | pmc = 4363808 | doi = 10.5312/wjo.v6.i2.263 }}</ref>

== Signs and symptoms ==

Movement of the shoulder is severely restricted, with progressive loss of both active and passive [[Engineering:Range of motion|range of motion]].<ref>{{cite journal | vauthors = Jayson MI | title = Frozen shoulder: adhesive capsulitis | journal = British Medical Journal | volume = 283 | issue = 6298 | pages = 1005–6 | date = October 1981 | pmid = 6794738 | pmc = 1495653 | doi = 10.1136/bmj.283.6298.1005 | jstor = 29503905 }}</ref> The condition is sometimes caused by injury, leading to lack of use due to [[Medicine:Pain|pain]], but also often arises spontaneously with no obvious preceding trigger factor (idiopathic frozen shoulder).  [[Medicine:Rheumatism|Rheumatic disease]] progression and recent shoulder [[Medicine:Surgery|surgery]] can also cause a pattern of pain and limitation similar to frozen shoulder. Intermittent periods of use may cause [[Medicine:Inflammation|inflammation]].

In frozen shoulder, there is a lack of [[Biology:Synovial fluid|synovial fluid]], which normally helps the shoulder joint, a ball and socket joint, move by [[Physics:Lubrication|lubricating]] the gap between the [[Biology:Humerus|humerus]] (upper arm [[Biology:Bone|bone]]) and the socket in the [[Biology:Scapula|shoulder blade]]. The shoulder capsule thickens, swells, and tightens due to bands of scar tissue ([[Medicine:Adhesion|adhesions]]) that have formed inside the capsule. As a result, there is less room in the joint for the humerus, making movement of the shoulder stiff and painful. This restricted space between the capsule and ball of the humerus distinguishes adhesive capsulitis from a less complicated, painful, stiff shoulder.<ref name="titleFrozen shoulder - Causes">{{cite web |url=http://www.nhs.uk/Conditions/Frozen-shoulder/Pages/Causes.aspx |title=Frozen shoulder – Causes |access-date=2011-07-05}}</ref>

== Diagnosis ==
One sign of a frozen shoulder is that the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. The movement that is most severely inhibited is external rotation of the shoulder.

People often complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion, or if bumped. A physical therapist, [[Medicine:Osteopath|osteopath]] or chiropractor, physician, athletic trainer, physician assistant, or nurse practitioner may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can be diagnosed if limits to the active range of motion (range of motion from active use of muscles) are the same or almost the same as the limits to the passive range of motion (range of motion from a person manipulating the arm and shoulder). An arthrogram or an MRI scan may confirm the diagnosis, though in practice this is rarely required.

The normal course of a frozen shoulder has been described as having three stages:<ref name="titleYour Orthopaedic Connection: Frozen Shoulder">{{cite web |url=http://orthoinfo.aaos.org/topic.cfm?topic=A00071 |title=Your Orthopaedic Connection: Frozen Shoulder |access-date=2008-01-28}}</ref> Though according to one practice guideline there are four stages.<ref name = "Kelley_2013" /> The first stage preceding the stage one listed below. This preceding stage can be present up to 3 months and during this stage people describe sharp pain at end ranges of motion, achy pain at rest, and sleep disturbances. Early loss of external rotation with an intact rotator cuff is a hallmark sign in this stage.<ref name = "Kelley_2013" />

* Stage one: The "freezing" or painful stage, which may last from six weeks to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.<ref>{{Cite web|url=http://www.jeremyburnhammd.com/frozen-shoulder-adhesive-capsulitis/|title=Frozen Shoulder Diagnosis & Management|last=Burnham |first=Jeremy | name-list-format = vanc |date=|website=|publisher=|access-date=25 January 2017}}</ref>
* Stage two: The "frozen" or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage generally lasts from four to nine months.
* Stage three: The "thawing" or recovery, when shoulder motion slowly returns toward normal. This generally lasts from 5 to 26 months.<ref name="pthealth.ca">{{Cite web|url=https://www.pthealth.ca/blog/seeking-care-can-shorten-recovery-time-for-frozen-shoulder/|title=Reduce Frozen Shoulder Recovery Time|date=2016-06-24|access-date=2016-07-12}}</ref>

=== Medical imaging ===
Imaging features of adhesive capsulitis are seen on non-contrast MRI, though MR arthrography and invasive arthroscopy are more accurate in diagnosis.<ref>Neviaser TJ. Arthrography of the shoulder. Orthop Clin North Am 1980; 11:205-17</ref> Ultrasound and [[Physics:Magnetic resonance imaging|MRI]] can help in diagnosis by assessing the coracohumeral ligament, with a width of greater than 3&nbsp;mm being  60% [[Sensitivity and specificity|sensitive]] and 95% [[Sensitivity and specificity|specific]] for the diagnosis. The condition can also be associated with edema or fluid at the rotator interval, a space in the shoulder joint normally containing fat between the supraspinatus and subscapularis tendons, medial to the rotator cuff. Shoulders with adhesive capsulitis also characteristically fibrose and thicken at the axillary pouch and rotator interval, best seen as dark signal on [[Physics:Physics of magnetic resonance imaging|T1]] sequences with edema and inflammation on T2 sequences.<ref>{{cite journal | vauthors = Shaikh A, Sundaram M | title = Adhesive capsulitis demonstrated on magnetic resonance imaging | journal = Orthopedics | volume = 32 | issue = 1 | pages = 2–62 | date = January 2009 | pmid = 19226048 | doi = 10.3928/01477447-20090101-20 }}</ref> A finding on ultrasound associated with adhesive capsulitis is hypoechoic material surrounding the long head of the biceps tendon at the rotator interval, reflecting fibrosis. In the painful stage, such hypoechoic material may demonstrate increased vascularity with Doppler ultrasound.<ref>Arend CF. Ultrasound of the Shoulder. Master Medical Books, 2013. Chapter on ultrasound findings of adhesive capsulitis available at [http://www.shoulderus.com/ultrasound-of-the-shoulder/adhesive-capsulitis-spectrum-of-ultrasound-findings/ ShoulderUS.com]</ref>

== Prevention ==
To prevent the problem, a common recommendation is to keep the shoulder [[Biology:Joint|joint]] fully moving to prevent a frozen shoulder. Often a shoulder will hurt when it begins to freeze. Because pain discourages movement, further development of [[Medicine:Adhesion|adhesions]] that restrict movement will occur unless the joint continues to move full range in all directions (adduction, abduction, flexion, rotation, and extension). [[Medicine:Physical therapy|Physical therapy]] and [[Medicine:Occupational therapy|occupational therapy]] can help with continued movement.

However, a 2004 study showed that "supervised neglect" (which is supportive therapy and exercises within pain limits) <ref name="Diercks2004" /> has a higher rate of recovery versus intense physical therapy and passive stretching.<ref name="Diercks2004">{{cite journal | vauthors = Diercks RL, Stevens M | title = Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years | journal = Journal of Shoulder and Elbow Surgery | volume = 13 | issue = 5 | pages = 499–502 | year = 2004 | pmid = 15383804 | doi = 10.1016/j.jse.2004.03.002 | url = https://www.researchgate.net/publication/8330806 }}</ref>
The above paragraph shouldn't be taken as advice to ignore - limiting your motions to avoid the pain caused by shoulder motions is exactly why serious cases of this problem can develop.

== Management ==

Management of this disorder focuses on restoring joint movement and reducing shoulder pain, involving medications, physical therapy, and/or surgical intervention. Treatment may continue for months; there is no strong evidence to favor any particular approach.<ref name="Ewald2011">{{cite journal | vauthors = Ewald A | title = Adhesive capsulitis: a review | journal = American Family Physician | volume = 83 | issue = 4 | pages = 417–22 | date = February 2011 | pmid = 21322517 }}</ref>

Medications frequently used include NSAIDs; corticosteroids are used in some cases either through local injection or systemically. Oral steroids may provide short-lived benefits in range of movement and pain.<ref>{{cite journal | vauthors = Buchbinder R, Green S, Youd JM, Johnston RV | title = Oral steroids for adhesive capsulitis | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD006189 | date = October 2006 | pmid = 17054278 | doi = 10.1002/14651858.cd006189 }}</ref> However, if a person has [[Medicine:Diabetes mellitus|Diabetes Mellitus]], then using corticosteroids can do more harm than good. Steroid injections could influence the blood sugar level, and current evidence suggested that physical therapy could be a better alternative.<ref name=":0">{{cite journal | vauthors = Sun Y, Lu S, Zhang P, Wang Z, Chen J | title = Steroid Injection Versus Physiotherapy for Patients With Adhesive Capsulitis of the Shoulder: A PRIMSA Systematic Review and Meta-Analysis of Randomized Controlled Trials | journal = Medicine | volume = 95 | issue = 20 | pages = e3469 | date = May 2016 | pmid = 27196452 | pmc = 4902394 | doi = 10.1097/MD.0000000000003469 }}</ref> The benefits of steroid injections may also be short-lived.<ref>{{cite journal | vauthors = Buchbinder R, Green S, Youd JM | title = Corticosteroid injections for shoulder pain | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD004016 | date = 2003-01-20 | pmid = 12535501 | pmc = 6464922 | doi = 10.1002/14651858.cd004016 }}</ref> It is unclear whether ultrasound guided injections can improve pain or function over intramuscular injections.<ref>{{cite journal | vauthors = Bloom JE, Rischin A, Johnston RV, Buchbinder R | title = Image-guided versus blind glucocorticoid injection for shoulder pain | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD009147 | date = August 2012 | pmid = 22895984 | doi = 10.1002/14651858.cd009147.pub2 }}</ref> Manual therapists like osteopaths, chiropractors and physical therapists (physiotherapists) may include massage therapy and daily extensive stretching.<ref name="Ewald2011"/> 

=== Physical therapy ===
PT treatment is utilized as an initial treatment in adhesive capsulitis or frozen shoulder with the use of different Range of motion(ROM) exercises and manual therapy techniques of shoulder joint to restore range and function. Good results have been reported with PT treatment alone or in combination with various other conservative treatments. Initial conservative management might be successful in up to 90% cases. In case of stubborn, non-responsive adhesive capsulitis, it may achieve improved results after surgical procedure and postoperative rehabilitation although there are many other important factors which decide if a person is a candidate for surgery or not. <ref>{{cite journal | vauthors = Cho CH, Bae KC, Kim DH | title = Treatment Strategy for Frozen Shoulder | journal = Clinics in Orthopedic Surgery | volume = 11 | issue = 3 | pages = 249–257 | date = September 2019 | pmid = 31475043 | pmc = 6695331 | doi = 10.4055/cios.2019.11.3.249 }}</ref>

Physical therapists may utilize [[Medicine:Joint mobilization|joint mobilization]]s directly at the glenohumeral joint to decrease pain, increase function, and increase range of motion as another form of treatment.<ref name="Kelley_2013" /> Additional interventions include modalities such as ultrasound, shortwave diathermy, laser therapy and electrical stimulation.<ref name="Kelley_2013" /><ref>{{cite journal | vauthors = Green S, Buchbinder R, Hetrick S | title = Physiotherapy interventions for shoulder pain | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD004258 | date = 2003-04-22 | pmid = 12804509 | doi = 10.1002/14651858.cd004258 }}</ref> Another osteopathic technique used to treat the shoulder is called the Spencer technique.

If these measures are unsuccessful, [[Medicine:Joint manipulation|manipulation]] of the shoulder under general anesthesia to break up the adhesions is sometimes used.<ref name="Ewald2011"/> [[Medicine:Hydrodilatation|Hydrodilatation]] or distension arthrography is controversial.<ref>{{cite journal | vauthors = Tveitå EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E | title = Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial | journal = BMC Musculoskeletal Disorders | volume = 9 | pages = 53 | date = April 2008 | pmid = 18423042 | pmc = 2374785 | doi = 10.1186/1471-2474-9-53 }}</ref> However, few studies show that arthrographic distension may play a positive role in reducing pain and, therefore, improve range of movement and function.<ref>{{cite journal | vauthors = Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M | title = Arthrographic distension for adhesive capsulitis (frozen shoulder) | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD007005 | date = January 2008 | pmid = 18254123 | doi = 10.1002/14651858.cd007005 }}</ref> [[Medicine:Surgery|Surgery]] to cut the adhesions (capsular release) may be indicated in prolonged and severe cases; the procedure is usually performed by [[Medicine:Arthroscopy|arthroscopy]].<ref>{{cite journal | vauthors = Baums MH, Spahn G, Nozaki M, Steckel H, Schultz W, Klinger HM | title = Functional outcome and general health status in patients after arthroscopic release in adhesive capsulitis | journal = Knee Surgery, Sports Traumatology, Arthroscopy | volume = 15 | issue = 5 | pages = 638–44 | date = May 2007 | pmid = 17031613 | doi = 10.1007/s00167-006-0203-x }}</ref> Surgical evaluation of other problems with the shoulder, e.g., [[Medicine:Subacromial bursitis|subacromial bursitis]] or [[Medicine:Rotator cuff tear|rotator cuff tear]] may be needed.

Resistant adhesive capsulitis may respond to open release surgery. This technique allows the surgeon to find and correct the underlying cause of restricted glenohumeral movement such as contracture of coracohumeral ligament and rotator interval.<ref name="D’Orsi Via Frizziero Oliva 1911 p. ">{{cite journal | vauthors = D'Orsi GM, Via AG, Frizziero A, Oliva F | title = Treatment of adhesive capsulitis: a review | journal = Muscles, Ligaments and Tendons Journal | volume = 2 | issue = 2 | pages = 70–8 | date = April 2012 | pmid = 23738277 | pmc = 3666515 }}</ref>

A study published in 2004 by Diercks and Stevens showed that supervised neglect had a better outcome than intense physical therapy. "Supervised neglect" meant home exercises (pendulum exercises and active exercises within the painless range) and resumption of all activities that were tolerated. "Intense physical therapy" meant passive stretching and manual mobilization together with exercises beyond the pain threshold. Both groups received anti-inflammatory medication (NSAIDs) or analgesics as necessary; neither group received corticosteroid medication or any treatment under anesthesia. The proportion of patients achieving normal or near-normal painless shoulder function at 24 months was 89% in the supervised neglect group, vs 63% in the intense physical therapy group.<ref name="Diercks2004"/>

A more recent 2016 review had evaluated the efficacy and safety of steroid injections compared to physical therapy. The present results showed that both interventions had similar effect in improving shoulder function and decreasing pain.<ref name=":0" /> Although, other studies have reported to find a combination of manual therapy and exercise as less effective than glucocorticoid injections.<ref>{{cite journal | vauthors = Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, Buchbinder R | title = Manual therapy and exercise for adhesive capsulitis (frozen shoulder) | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD011275 | date = August 2014 | pmid = 25157702 | doi = 10.1002/14651858.cd011275 }}</ref>

== Epidemiology ==
The incidence of adhesive capsulitis is approximately 3 percent in the general population, but some researchers cast doubt on this often cited figure because of how often the disease is misdiagnosed; this would make the disease much rarer than previously thought.<ref>{{Cite journal |title=Time for a new name for frozen shoulder—contracture of the shoulder |last=Bunker |first=Tim | name-list-format = vanc |journal=Shoulder&Elbow |volume = 1 |pages=4–9|date=2009 |doi=10.1111/j.1758-5740.2009.00007.x }}</ref> Occurrence is rare in children and people under 40 but peaks between 40 and 70 years of age.<ref name="Ewald2011" /> At least in its idiopathic form, the condition is much more common in women than in men (70% of patients are women aged 40–60). Frozen shoulder is more frequent in diabetic patients and is more severe and more protracted than in the non-diabetic population.<ref name="titleQuestions and Answers about Shoulder Problems">{{cite web |url=http://www.niams.nih.gov/Health_Info/Shoulder_Problems/default.asp |title=Questions and Answers about Shoulder Problems |access-date=2008-01-28}}</ref>

People with [[Medicine:Diabetes|diabetes]], [[Medicine:Stroke|stroke]], [[Medicine:Lung disease|lung disease]], [[Medicine:Rheumatoid arthritis|rheumatoid arthritis]], or heart disease are at a higher risk for frozen shoulder. Injury or surgery to the shoulder or arm may cause blood flow damage or the capsule to tighten from reduced use during recovery.<ref name="titleFrozen shoulder - Causes"/> Adhesive capsulitis has been indicated as a possible [[Medicine:Side effect|adverse effect]] of some forms of highly active [[Biology:Retrovirus|antiretroviral]] therapy (HAART). Cases have also been reported after breast and lung surgery.<ref>{{cite web|last1=Adam|first1=Rocchi | name-list-format = vanc |title=Frozen Shoulder – What, Where, Why and How To Get Relief|url=http://spinescan.com.au/frozen-shoulder-what-where-why-and-how-to-get-relief/|website=Spine Scan|publisher=Spine Scan|access-date=28 July 2016|date=10 May 2016}}</ref>

== See also ==
* [[Medicine:Calcific tendinitis|Calcific tendinitis]]
* [[Medicine:Milwaukee shoulder syndrome|Milwaukee shoulder syndrome]]

== References ==
{{Reflist}}

This article contains text from the public domain document "[http://orthoinfo.aaos.org/topic.cfm?topic=A00071 Frozen Shoulder]", American Academy of Orthopaedic Surgeons.

== Further reading ==
{{refbegin}}
* {{cite journal | vauthors = Siegel LB, Cohen NJ, Gall EP | title = Adhesive capsulitis: a sticky issue | journal = American Family Physician | volume = 59 | issue = 7 | pages = 1843–52 | date = April 1999 | pmid = 10208704 | url = http://www.aafp.org/afp/990401ap/1843.html }}
* [http://www.melbourneradiology.com.au/index.php?option=com_content&view=article&id=100&Itemid=129 Radiology image sequence demonstrating CT guided shoulder hydrodilatation]
* [http://www.shoulderus.com/ultrasound-of-the-shoulder/adhesive-capsulitis "Adhesive Capsulitis"] from Arend CF. Ultrasound of the Shoulder. Master Medical Books, 2013.
* A "Neuromanual" treatment for frozen shoulder using local anesthetic from the [http://frozenshoulderclinic.com/trigenics-oat-procedure/treatment-of-adhesive-capsulitis-using-local-anesthetic/ Russian Journal of Manual Therapy, 2012]
{{refend}}

== External links ==
{{Medical resources
|  DiseasesDB     = 34114 
|  ICD10          = {{ICD10|M|75|0|m|70}} 
|  ICD9           = {{ICD9|726.0}} 
|  ICDO           =  
|  OMIM           =  
|  MedlinePlus    = 000455 
|  eMedicineSubj  = orthoped 
|  eMedicineTopic = 372 
|  MeshID         = 
}}
{{Soft tissue disorders}}


{{DEFAULTSORT:Adhesive Capsulitis Of Shoulder}}
[[Category:Soft tissue disorders]]
[[Category:Orthopedic surgical procedures]]

{{Sourceattribution|Adhesive capsulitis of shoulder|1}}