Adhesive Capsulitis (Frozen Shoulder)

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Adhesive Capsulitis (Frozen Shoulder)

Adhesive Capsulitis (commonly known as Frozen Shoulder) is a condition that causes shoulder pain and restricted range of motion. It most commonly affects women and individuals aged between 40 and 60.

The etiology of Adhesive Capsulitis is not well understood and is predominantly an idiopathic condition. However, it has an increased prevalence in patients with diabetes mellitus and thyroid disorders. Pathophysiology associated with Adhesive Capsulitis involves capsular hyperplasia and fibrosis. Histological changes have been described as progressing from inflammatory cell infiltration of the synovium to synovial proliferation, leading to an eventual formation of dense collagenous tissue within the capsule. This process supports the hypothesis that initial capsular inflammation leads to reactive fibrosis.

Subtypes – There are two subtypes of Adhesive Capsulitis:

• Primary: Insidious (idiopathic)
• Secondary: Begins abruptly following an injury (which may be relatively trivial) or from the subsequent immobilization following an injury

Stages – The clinical course of Adhesive Capsulitis progresses through three stages:

• Stage 1: ‘Freezing’ or ‘Painful’ – Gradually worsening pain and stiffness (lasting 2 to 9 months).
• Stage 2: ‘Frozen’ or ‘Transitional’ – Pain reduction but continued stiffness and possible development of muscle wasting (lasting 4 to 12 months).
• Stage 3: ‘Thawing’ or ‘Recovery’ – Further pain reduction and gradual improvement in range of movement (lasting 6 to 24 months).

The following findings reflect Stages 1 and 2 of Adhesive Capsulitis:

• Gradual onset of steadily worsening shoulder pain
• A gradual reduction in shoulder movement
• Sharp pain at the end of shoulder movement
• Pain aggravated by sleeping on the side of involvement
• Difficulty in grooming (e.g., brushing hair), dressing, reaching behind the back, and performing overhead activities

• Shoulder muscle atrophy may be present on inspection
• Loss of pendulousness of the arm during walking
• Moderate to marked global loss of active and passive glenohumeral joint motion (most notably for external rotation, flexion, abduction, and internal rotation)
• Positive Apley’s Scratch tests
• Tenderness over the anterior and posterior glenohumeral joint on palpation

Adhesive Capsulitis is primarily a clinical diagnosis. Plain radiography can assist in screening for other pathologies (e.g., osteoarthritis or osteonecrosis). MRI may be used to confirm a diagnosis of Adhesive Capsulitis and screen for other soft tissue pathologies (e.g., supraspinatus tendon and joint capsular tears).

The following are examples of “red flags” for patients presenting with shoulder pain and dysfunction:

• History of a significant injury
• Severe or focal pain
• Unrelenting pain
• Nocturnal pain
• Unexplained weight loss
• Fever
• Deformity
• Significant swelling
• Leg pain arising after a prolonged period of immobility or bed rest
• Presence of tingling, numbness, burning or other neurological impairment
• Loss of distal leg pulses
• Significant loss of range of motion
• Severe tenderness on palpation or severe pain with any examination procedure

If any “red flags” are identified during history taking and clinical examination, referral for urgent medical evaluation and further investigation is warranted.

• Inform your patient that, in most cases, Frozen Shoulder is a self-limited disease with high spontaneous recovery rates but could take 8 months or longer.
• The key to earlier recovery is to avoid any aggravating activities. Warn your patient that any daily activities, exercises, and stretches that cause shoulder pain must be avoided as these will only prolong the condition. Simple messages that you can use to convey home advice include:
  • “Any activity that hurts your shoulder will delay your recovery.”
  • “Avoid, at any cost, raising your affected arm above your shoulder level.”
  • “Wear button-up or zipper-front clothing to avoid aggravating your shoulder condition by having to pull clothing off over your head.”
  • “If painful, do not stretch your shoulder to increase its range of movement. The more you try, the more your shoulder will tighten up.”
• Patients with shoulder pain may experience discomfort during sleep. Sleeping with the involved arm supported by a pillow may reduce that discomfort.

Differential Diagnosis

In addition to Adhesive Capsulitis, the following conditions should be considered in patients presenting with global loss of shoulder mobility:

• Osteoarthritis
• Inflammatory arthritis
• Fracture and dislocation
• Malignancy