Adhesive capsulitis (Frozen shoulder)

• risk factors
  • diabetes
  • thyroid dysfunction
  • hypercholesterolaemia
  • hypertension
  • immobilized for a period of time due to surgery, a fracture, or other injury
• incidence of 3–5%
• peak age is 56 years
• occurs slightly more often in women than men.

What is frozen shoulder?

• a condition characterized by functional restriction of both active and passive shoulder motion
• for which radiographs of the glenohumeral joint are essentially unremarkable except for the possible presence of osteopenia or calcific tendonitis
• osteopenia results from limb and shoulder disuse
• aetiology is unclear

Symptoms

• Pain + Restriction 
• mechanical restriction in all planes of movement of the glenohumeral joint
  • due to glenohumeral capsular tightness and restriction without any evidence of adhesions. 
  • It occurs when the capsule, or the soft tissue envelope, becomes scarred and contracted, making the shoulder tight, painful and stiff
• Spontaneous. no identifiable cause or trigger
• pain is often described as a poorly localized, deep ache
• No Red flags (fever, night sweats, and unexplained weight loss)
• No Neuropathic symptoms
• resolves spontaneously after 1–3 years
• 40% of patients may have persistent symptoms
• 7–15% having some degree of permanent loss of movement

Clinical phases of frozen shoulder (each phase is overlapping)
Clinical phase	Description	Clinical details
Phase one	Painful phase or pain-predominant phase	Lasts 2–9 monthsProgressive stiffening and increasing pain on movement and at nightNo history of shoulder trauma
Phase two	Stiffening, freezing or stiffness predominant phase	Lasts 4–12 monthsGradual reduction of pain but stiffness persists with considerable restriction in range of motionPain gradually subsides but stiffness remainsPain may be apparent only at the extremes of movementGross reduction of glenohumeral movements, with near total obliteration of external rotation
Phase three	Resolution or thawing phase	Lasts 12–42 monthsVariable improvement in range of motion with resolution of stiffness

Differentials

Physical Examination

• may have lost the natural arm swing that occurs with walking.
• Muscle atrophy of the shoulder girdle may be present. 
• Loss of motion with forward flexion, abduction, and external and internal rotation should raise suspicion for adhesive capsulitis
  • The pathognomonic sign of frozen shoulder is almost complete loss of active and passive external rotation. 
  • Limitation to active and passive abduction, forward flexion and/or internal rotation may also be found.
• Palpation may yield vague, diffuse tenderness over the anterior and posterior shoulder.
  • Focal tenderness over a specific structure is rare; its presence suggests another diagnosis or concomitant pathology, such as rotator cuff or biceps tendinopathy.
• Neurovascular testing should be performed on the upper extremity of the involved side to rule out neurologic conditions such as cervical radiculopathy. Palpation and range-of-motion testing of the cervical spine should also be performed.

Investigations

• predominantly a clinical diagnosis
• Xray can rule out other conditions and detect concomitant pathology
  • it is also useful to assess for Pancoast tumors, advanced glenohumeral arthritis, pathologic fracture, avascular necrosis, and calcific rotator cuff and biceps tendinopathy.
• Ultrasound
  • limitation of movement of the supraspinatus
  • limited external rotation, identified when positioning for subscapularis tendon assessment
  • thickened coracohumeral ligament (CHL), inferior glenohumeral capsule 
• MRI/MR arthrography
  • joint capsule thickening
  • abnormal soft tissue thickening within the rotator interval with signal alteration
  • pericapsular scarring 

Management

1. Education
   1. The nature of the condition
   2. The natural history
   3. The potential chronicity of the condition
2. Shoulder Pain and Disability Index (SPADI)
   1. provides a baseline of current pain and disability, therefore allowing a serial measure of progress and how the condition affects the patient’s quality of life and ability to work and function safely
3. Regular and breakthrough analgesia
   1. Start with simple regular analgesia; care should be taken with regular and prolonged use of nonsteroidal anti-inflammatory drugs if these are used
   2. Supplement with stronger breakthrough analgesia
   3. Topical creams, lotions and ointments are ineffective, but their use may be reasonable if the patient perceives there is benefit and no harm is being done
4. Physiotherapy
   1. Involve early
   2. Intervention strategies will vary depending on the phase
5. Intra-articular corticosteroid injection
   1. More effective the earlier it is given
   2. Aseptic technique is necessary
   3. Accuracy can be ensured using anatomical landmarks or image guidance
6. Other injection therapies
   1. Hydrodilatation has been shown to be effective and safe
   2. The addition of a small amount of local anaesthetic is beneficial
7. Surgical options
   1. joint manipulation under anesthesia and capsular release.
   2. Surgical release of the capsule