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Adhesive Capsulitis (Frozen Shoulder)

  • Condition of the shoulder characterized by functional loss of passive and active shoulder motion
  • The etiology is unclear

Epidemiology

  • Affects females more than males
  • More common in 40-60 year olds

Etiology/risk factors

  • Primary adhesive capsulitis (AC) is idiopathic
  • Post-traumatic – following proximal humerus fracture
  • Post-surgical – following rotator cuff repair or axillary dissection
  • Risk factors include several systemic diseases – e.g. diabetes mellitus, connective tissue disease, thyroid disorders, autoimmune disease
Anatomy of the shoulder joint
  • The joint capsule is a fibrous sheath which encloses the structures of the shoulder joint
    • The capsule is formed by the glenohumeral (GH) ligaments
  • Glenohumeral ligaments – superior, middle and inferior
    • Main source of stability for the shoulder, prevent it from dislocating anteriorly
  • The rotator cuff interval is a triangular region between the anterior border of supraspinatus and superior border of subscapularis  
    • Contains the superior glenohumeral ligament and the coracohumeral ligament

Pathoanatomy

  • Inflammation and fibroblastic proliferation of the joint capsule – leads to thickening, fibrosis and adherence of the capsule to itself and the humerus
    • There is an abundance of fibroblasts and type III collagen
    • Leads to a mechanical block to motion
  • Reduction in synovial fluid which normally lubricates the joint
  • Thickening and fibrosis of the rotator cuff interval –  leads to contractions and fibrosis of the GH ligaments

Classification

Clinical stages

  • Freezing/painful – gradual onset of diffuse pain
  • Frozen/stiff – decreased range of motion affecting daily activities
  • Thawing – gradual return of motion

Arthroscopic changes

  • Stage 1 – patchy, fibrinous synovitis
  • Stage 2 – capsular contractions and fibrinous adhesions
  • Stage 3 – increasing contraction, synovitis resolving
  • Stage 4 – severe contraction

Clinical features

  • Insidious onset of generalised shoulder pain
  • Variable severity of pain and loss of motion, depending on stage of presentation (see classification)
  • Pain at rest and difficulty sleeping

Diagnosis

Physical exam

  • Symmetric loss of active and passive range of motion
  • External rotation deficit is most common

X-ray

  • To rule out osteoarthritis/dislocation

Treatment

  • Physiotherapy
  • NSAIDs
  • Heat/cryo-therapy
  • Intra-articular steroid injections

Operative – to release adhesions

  • Manipulation under anaesthesia (MUA) – to break up adhesions
    • Higher rate of failure in diabetic patients
  • Arthroscopic or open capsular release
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