Adhesive capsulitis of the shoulder
Updates to Article Attributes
Adhesive capsulitis of the shoulder (also known as frozen shoulder) is a condition characterised by thickening and contraction of the shoulder joint capsule and surrounding synovium. Adhesive capsulitis can rarely affect other sites such as the ankle 8.
Epidemiology
The incidence in the general population is thought to be 3-5%. Adhesive capsulitis typically affects women in the 5th to 6th decades of life, although patients with co-morbidities such as diabetes may develop the condition at earlier ages. The incidence in patients with diabetes is reported to be 2 to 4 times higher than in the general population.
Clinical presentation
Adhesive capsulitis presentation can be broken into three distinct stages:
-
freezing: painful stage
- patients may not present during this stage because they think that eventually the pain will resolve if self-treated.
- as the symptoms progress, pain worsens and both active and passive range of motion (ROM) becomes more restricted
- this can eventually result in the patient seeking medical consultation
- typically lasts between 3 and 9 months and is characterized by an acute synovitis of the glenohumeral joint
-
frozen: transitional stage
- most patients will progress to the second stage
- during this stage shoulder pain does not necessarily worsen
- because of pain at end ROM, use of the arm may be limited causing muscular disuse
- can last between 4 to 12 months
- the common capsular pattern of limitation has historically been described as diminishing motions with external shoulder rotation being the most limited, followed closely by shoulder flexion, and internal rotation
- there eventually becomes a point in the frozen stage that pain does not occur at the end of ROM
-
thawing stage
- begins when ROM begins to improve
- lasts anywhere from 12 to 42 months and is defined by a gradual return of shoulder mobility
Pathology
Adhesive capsulitis is divided into two main types:
-
primary or idiopathic
- absence of preceding trauma
-
secondary
- major or minor repetitive trauma
- shoulder or thoracic surgery
- endocrine, e.g. diabetes, hyperthyroidism 12
- rheumatological conditions
Radiographic features
Fluroscopic arthrography
Described features include:
- limited injectable fluid capacity of the glenohumeral joint
- small dependent axillary fold
- small subscapularis bursa
- irregularity of the anterior capsular insertion at the anatomic neck of the humerus
- lymphatic filling may be present
Ultrasound
Limitation of movement of the supraspinatus is considered a sensitive feature 7. A thickened coracohumeral ligament (CHL) can also be a suggestive feature of adhesive capsulitis 9.
MRI/MR arthrography
- normal inferior glenohumeral ligament measures <4 mm and is best seen on coronal oblique images at the mid glenoid level; in adhesive capsulitis, the axillary recess may show thickening ≥1.3 cm
- joint capsule thickening 2
- abnormal soft tissue thickening within the rotator interval with signal alteration
- abnormal soft tissue encasing the biceps anchor
- variable enhancement of the capsule and synovium within the axillary recess and rotator interval
Other MR arthrography features include
- thickening of the coracohumeral ligament (CHL) 4
- subcoracoid triangle sign 4
Treatment and prognosis
Adhesive capsulitis is typically a self-limiting disease that improves over 1-2 years. Treatment options include:
- physiotherapy
- corticosteroid injections
- glenohumeral hydrodilatation
- closed manipulation under
anesthesiaanaesthesia - arthroscopic capsular release with lysis of adhesions
-<li>abnormal soft tissue thickening within the rotator interval</li>- +<li>abnormal soft tissue thickening within the rotator interval with signal alteration</li>
-<li>closed manipulation under anesthesia</li>- +<li>closed manipulation under anaesthesia</li>
Image 5 MRI (PD fat sat) ( create )
Image 6 MRI (T2 fat sat) ( create )
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