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LORI B. SIEGEL, M.D., NORMAN J. COHEN, M.D., and
ERIC P. GALL, M.D.
Finch University of Health Sciences/Chicago Medical
School
North Chicago, Illinois
A patient information
handout on adhesive
capsulitis, written by the
authors of this article, is
provided on page 1851.
The shoulder is a very complex joint that is crucial to many activities of daily living. Decreased
shoulder mobility is a serious clinical finding. A global decrease in shoulder range of motion is called
adhesive capsulitis, referring to the actual adherence of the shoulder capsule to the humeral head.
Adhesive capsulitis is a syndrome defined as idiopathic restriction of shoulder movement that is
usually painful at onset. Secondary causes include alteration of the supporting structures of and
around the shoulder, and autoimmune, endocrine or other systemic diseases. The three defined
stages of this condition are the painful stage, the adhesive stage and the recovery stage. Although
recovery is usually spontaneous, treatment with intra-articular corticosteroids and gentle but persistent
physical therapy may provide a better outcome, resulting in little functional compromise.
Theshoulderisacomplexanatomicstructurethatallowsmovementinmanyplanes.Physiciansand
patientsalikedon'toftenthinkabouttheimportanceoftheshoulderjointuntilitsfunctionbecomes
compromised.Itthenbecomesobvioushowcrucialitisformanyessentialactivities.Theexpression
"Ifyoudon'tuseit,youloseit"appliesperfectlytodiseasesoftheshoulderbecauseanyvoluntaryor
involuntaryguardingoftheshouldermayresultinlossofmobility.Theterm"frozenshoulder"has
beenlooselyappliedtoconditionswhentheshoulderisworkingatlessthanitsoptimalrange.
Becausetheshoulderjointissocomplex,itisimportanttodeterminetheprecisecauseforlossof
shouldermobility.Itisparamountthatphysiciansuseproperterminologysothattheycan
communicateeffectivelyandtreatpatientsappropriately.
Definition of Terms
Manytermsareusedtodescribelimitationofshoulder
TABLE 1
movement,andallofthemimplyastiffshoulderwith Terms Used to Describe Limited
decreasedrangeofmotion(Table1).Thesetermsare Shoulder Mobility
attemptstodescribetheprobableunderlying
pathophysiologicprocess(i.e.,bursalorcapsular
originsofinflammation).Theywereusedtodescribe
Frozen shoulder
Adhesive capsulitis
Pericapsulitis
Periarthritis
Adherent bursitis
Obliterative bursitis
conditionsthataredifficulttounderstandandexplainand,althoughofhistoricinterest,theyare
confusingandarebestdiscarded.Theterm"frozenshoulder"encompassesmanyoftheconceptsof
thetermsinTable1,butittooisconfusingandnotalwaysaccurate.Thecorrecttermfortrueglobal
decreaseinshoulderrangeofmotionisadhesivecapsulitis,relatedtothesurgicalfindingsofactual
adherenceofthecapsuletothehumeralhead.
1,2
Adhesivecapsulitisisasyndromedefinedinitspurestsenseasidiopathicpainfulrestrictionof
shouldermovementthatresultsinglobalrestrictionoftheglenohumeraljoint.Itisnotassociatedwith
aspecificunderlyingcondition.Ithasalsobeendescribedasaconditionof"unknownetiology
characterizedbygraduallyprogressive,painfulrestrictionofalljointmotion...withspontaneous
restorationofpartialorcompletemotionovermonthstoyears." Toavoidconfusion,theterm
3
"adhesivecapsulitis"shouldbeusedtorefertotheprimaryidiopathicconditionandtheterm
"secondaryadhesivecapsulitis"shouldbeappliedtotheconditionthatisassociatedwith,orresults
from,otherpathologicstates.Eachcasemustbeevaluatedtodetermineiftherestrictionisidiopathic
(primary)ortheresultofanunderlyingsystemicillnessoranatomicprocess(secondary).Either
conditioncausespainanddecreasedshouldermobility.
Differential Diagnosis
Complaintsofshoulderpainormovementproblemsaredifficulttoevaluate.Manyshoulder
conditionshavesimilarsymptoms,causes,precipitatingfactorsandtreatments.Multiplepathologic
lesionsmaybepresentinasinglejoint. Inassessingapatient'sshoulderpain,thephysicianmust
4
distinguishbetweentrueglenohumeraljoint
problemsandextraarticularderangements.Active
rangeofmotionwillmostlikelybelimitedand
painfulinbothcases,butdecreasedpassiverangeof
motion,whichisoftenpainfulaswell,mostlikely
indicatestruejointpathology.
Ifthepatientisabletorelaxandtheexaminercan
elicitfullpassiverangeofmotion,theetiologyofthe
painismostlikelytobeextraarticular.Prolonged
softtissueproblems,however,mayeventuallylead
todecreasedshoulderrangeofmotionbecauseofthe
FIGURE 1. Anatomy of shoulder in diagnosis of
shoulder pain.
patient'sconstantguardingoftheshoulder.Itis
imperativetodeterminetheprecisesourceof
shoulderpain(Figure1)sothataprogramof
physicaltherapycanbeinitiatedtoprevent
compromiseofshouldermovement(Figure2).Extraarticularpainmayresultfromstrainor
inflammationofmuscles,tendonsorbursae.
Thedifferentialdiagnosisofshoulderproblemsisprotean,butphysiciansshouldbeabletoreadily
recallsomeofthemorecommoncausesofshoulderpainanddecreasedrangeofmotion.Bicipital
tendinitismayaffectactiveshouldermovementandisdiagnosedbyelicitingtendernesswhile
pressingonthelongheadbicipitaltendoninthebicipitalgroove.Thebicipitaltendonpassesthrough
theglenohumeraljoint.
PainonextensionmaybeelicitedbytestingforYergason'ssign(Figure3).Thepatientisaskedto
resistsupinationoftheforearmwhilethephysicianpressesonthebicipitaltendoninthegrooveon
thehumerus.Painwithresistedforwardflexion(Speed'stest),mayalsobepresent(Figure4).
Tendinitisoftherotatorcuffisthemostcommoncauseofshoulderpainandsecondarydecreased
shouldermobilitythatmanifestswithpainonpassiveandactiveabduction. Painisusuallygreater
5,6
withinternalrotationoftheshoulderthanwithexternalrotation.Thekeyfindingispainintherotator
cuffonactiveabduction,especiallyat60to100degreesofabduction.Ultimately,theremaybe
impingementandalossofmobility.Tendernessmaybeelicitedanteriorlyoverthehumeralhead
whenthearmisextended.Calcifictendinitismayalsoleadtoimpingement.
Thesubacromialandsubdeltoidbursaearecontiguousinmostpersons.Subacromialbursitis
manifestswithpainwhenthepatientliesonhisorhershoulder,orwithtendernessonpalpationofthe
spaceonthelateralaspectoftheshoulderjustinferiortotheacromionalongthedeltoid.Subacromial
bursitismayalsobeareactivephenomenoninapatientwitharotatorcuffinjury.Acromioclavicular
jointproblems,commonlyincludingosteoarthritis,mayalsoresultindecreasedpassivejointrangeof
motionandlocaltenderness.
Trueshoulderpainpresentswithtendernessonanteriororposteriorpalpation.Decreasedjointmotion
iscompensatedforbyanincreaseinscapulothoracicmotionduringflexionandabduction.Increased
scapulothoracicmotionstressesotherstructuresaroundtheshoulderandmayresultinmoreglobal
painsyndromes,guardinganddecreasedrangeofmotion.
Theevaluationofshoulderinstabilityisimportantinpatientswithshoulderpain.Symptomatic
subluxationmayclinicallymimicanacuterotatorcuff
injuryorbicipitaltendinitis.Ahighindexofsuspicionanda
detailedphysicalexaminationcombiningtheassessmentof
laxityinalldirectionswithstresstestscanhelpthe
physiciandeterminetheunderlyingcauseofpain.
Correctionofanymuscleimbalanceisparamounttopreservationofmobilityandfunction.Muscles
aroundtheneckandshouldergirdleshouldbepalpatedfortendernessortriggerpointstoassessfor
fibromyalgia,myofascialpainsyndromesandcervicalosteoarthritis.
Thecorrectdiagnosisinapatientwithrestrictedshouldermovementonphysicalexaminationandany
ofthepreviouslymentionedfindings,suchasbursitisortendinitis,issecondaryadhesivecapsulitis.
Theunderlyingconditionisdocumentedastheprimaryproblemleadingtosecondaryadhesive
capsulitis.
FIGURE 3.
Yergason's sign.
The patient
resists supination
of the forearm
while the
physician presses
on the bicipital
tendon.
FIGURE 4.
Speed's test. The
patient is asked to
flex the forearm
while the
physician
provides
resistance.
TABLE 2
The Three Stages of Adhesive
Capsulitis
Adhesive Capsulitis
Painful stage
Features,PresentationandNaturalHistory
Primaryidiopathicadhesivecapsulitisisdifficultto
define,diagnoseandmanage.Thisconditionaffects2
to3percentofthepopulation.Ittendstooccurin
patientsolderthan40yearsofageandmostcommonly
inpatientsintheir50sandinwomen.Fifteenpercent
ofpatientsdevelopbilateraldisease.Adhesive
capsulitishasbeenreportedinchildren.
Thenaturalhistoryofadhesivecapsulitisandits
clinicalcourseisdividedintothreestages:thepainful
Muscle spasm
Increasing pain at night and at rest
Adhesive stage
Less pain
Increasing stiffness and restriction of
movement
Decreasing pain at night and at rest
Discomfort felt at extreme ranges of
movement
Recovery stage
months.Musclespasmsinthetrapeziusalso
commonlyoccurduringthisphase.Ahistoryofaminorstrainorinjurybeforeonsetmaybenoted;
however,itisunclearwhethertheinitialstrainisanindependentphenomenonoranearlyawareness
ofthepainassociatedwiththeonsetofadhesivecapsulitis.
Commonly,patientsnoteadecreasedabilitytoreachbehindthebackwhenfasteningagarmentor
removingawalletfromabacktrouserpocket.Theinitialdiscomfortisdescribedbymanypatientsas
ageneralizedshoulderachewithdifficultypinpointingtheexactlocationofthediscomfort.Thepain
mayradiatebothproximallyanddistally,isaggravatedbymovementandalleviatedwithrest.Sleep
maybeinterruptedifthepatientrollsontheinvolvedshoulder.
Thisconditionprogressestooneofseverepainaccompaniedbystiffnessanddecreasedrangeof
motion.Thestiffeningincreasestothepointwherethenaturalarmswingthataccompaniesnormal
gaitislost. Thepatienttriestocompensateforthislossbyusingothermusclesandincreasing
8
scapularrotationtoaccomplishvariousactivities.Thisplacesadditionalstrainontheothermuscle
groups,leavingthemoverworkedandtender.
Thephysicalexaminationduringthepainfulstageofadhesivecapsulitismayrevealmusclespasm
anddiffusetendernessabouttheglenohumeraljointandthedeltoidmuscle.Anareaofpinpoint
tendernessisseldomfound.Withdiseaseprogressionandinlongstandingcases,disuseatrophyof
theshouldergirdlemayresult.Passiveandactiverangeofmotioninallplanesofshouldermovement
arelost(Figure5).Thisgloballossofmotionistheprimaryfactordistinguishingadhesivecapsulitis
frommanyoftheconditionsassociatedwithsecondaryadhesivecapsulitis.
Thesecondstage,theadhesivestage,involvesincreasingstiffnesswithdiminishingpain.Pain
decreasesatnight,anddiscomfortoccursonlyattheextremesofmotion,althoughmovementis
dramaticallydecreased.Thisstagelastsfourtosixmonths.
Thefinalstage,calledtherecoverystage,lastsfromonetothree
monthsandischaracterizedbyminimalpainbutsevererestrictionof
movement.Thislatterstageisselflimiting,withagradualand
spontaneousincreaseinrangeofmotion.Completerecovery,
however,isinfrequent.Theexternalrotationrangeofmotion
improvesfirst,followedbyabductionandinternalrotation.Short
FIGURE 5. Decreased passive
recoveryperiodsmayhaveassociatedboutsofpainbeforeeachphase
extension in a patient with
adhesive capsulitis.
ofimprovement.Althoughapproximately7to15percentofpatients
permanentlylosetheirfullrangeofmotion,onlyafewhaveatruefunctionaldisability.
9,10
Pathology
Thepathophysiologyofprimaryandsecondaryadhesivecapsulitisremainselusive.Itisbelievedthat
inpatientswithdiabetes,associatedmicrovasculardiseasecausesabnormalcollagenrepair,which
predisposesthemtoadhesivecapsulitis.Occasionally,fibrousstrandsareseentraversingthejoint
space(Figure6).Patientswithdiabetesoftenpresentwithfibrosiselsewhere(i.e.,Dupuytren's
contracture).Trauma,theassociatedtransientinflammatorystatewithgranulationtissue,andeventual
fibrousadhesionsandthickeningofthecapsulemaycauseadhesivecapsulitis.
1,8
Immobilizationisanintriguingpossibleetiologicfactorforadhesivecapulitisinpatientswithstroke
orpostmyocardialinfarction;however,prolongedcastingstudieshavenotsupportedthistheory.
8
Neuropathicmechanisms,includingsuprascapularnervecompression,havebeenconsidered,butnone
accountsformostcasesofadhesivecapsulitis.Althoughstrongevidencesuggestsanassociation
amongtheseneuropathicandvascularconditionsandadhesivecapsulitis,nopathophysiologic
mechanismsareconvincing.
Theoriesregardingautoimmunereactiontotendondegenerationhaveledtoimmunologic
investigations.Althoughrandomandinconsistent,theinflammatoryindexesmeasured(e.g.,
erythrocytesedimentationrate)werepartiallysupportedbecausetheywereslightlyelevatedand
improvedasthediseaseimproved. Synovialfluidoffersnocluestotheetiologyofadhesive
11
capsulitis.Biopsiesofthesynoviallininghaverevealedincreasedfibroblastsandvasculardilatation,
butfewornoperivascularinflammatorycells.
Evaluation
Thediagnosisofadhesivecapsulitisisprimarilyclinical.Ingeneral,thescapularrotationoccursat60
degreeswithactiveabductionoftheshoulder.Inanunaffectedperson,theshouldercanbepassively
abductedto90degreesevenwhenthephysicianholdsthescapula.Inabilitytoachievethe90degree
arcwithscapularstabilizationisthecluetothediagnosisinbothprimaryandsecondaryadhesive
capsulitis.Itisimportanttoassurethatthescapulaissecuredwhenassessingpassiverangeofmotion
(Figure7).
Radiographsareimportantinassessingrestrictedrangeofmotioninthediagnosisofsecondary
adhesivecapsulitis.Osteoarthritis,fracture,avascularnecrosis,crystallinearthropathy,calcific
tendinitisandneoplasmmaybedetectedonplainradiographs.Radiographsofpatientswithearly
adhesivecapsulitisarenormal.Laterchangessometimesshowosteopenia,cystlikechangesinthe
humeralheadandjointspacenarrowing.Achestradiographmaybeusefulinestablishingthe
diagnosisoftuberculosisormalignancyassociatedadhesivecapsulitis.
Arthrography,althoughinvasive,isusefultodocument
decreasedjointvolume.Theunaffectedshoulderwill
accommodate20to30mLofcontrastmaterial,whereas
theshoulderwithadhesivecapsulitiswillonlybeableto
hold5to10mL.Arthrogramsmayrevealanirregularity
ofthecapsularinsertionattheanatomichumeralneck
andadecreasedaxillaryfold.From10to30percentof
normalfindings.Arthrographyshouldbereservedfor
useinpatientswhosediagnosisremainsuncertainfollowingphysicalexaminationandradiography.
Arthroscopymayhavealimitedroleinthediagnosisofotherdiseasesthatmimicadhesivecapsulitis,
butitdoesnotaidinthediagnosisofadhesivecapsulitisitselfandisnotusedfrequently. The
12
usefulnessofmagneticresonanceimaging(MRI)inthediagnosisofadhesivecapsulitishasalsobeen
evaluated. StudiesrevealedthatsomechangesseenonMRIarespecificandsensitiveforadhesive
13
capsulitis;however,thedecreaseinjointfluidisnotappreciated.MRImaybecomeauseful,
noninvasivewaytodocumentcapsularthickening,butfurtherstudiesareneeded.Inmostcases,the
diagnosisofadhesivecapsulitisisclinical;however,ifanyimagingisnecessary,arthrography
remainstheprocedureofchoice.Iftherearenounderlyingillnesses,laboratoryinvestigationswillbe
unremarkable.
oftenhavereferredshoulderpainfromtheheart,neck,diaphragm,liverorspleen.Itisunclearwhy
patientswithahistoryofmyocardialinfarctions,cerebrovascularaccidentsandchronicpulmonary
diseases,suchastuberculosisandpulmonarycancer,arealsopredisposedtoadhesivecapsulitis.
Patientswithreflexsympatheticdystrophy(relatedtosomeoftheseevents)mayhaverestrictedrange
ofmotionoftheshoulderthatbecomespermanentinthelaterstagesofdisease.Somepatientsmay
alsodevelopreflexsympatheticdystrophyasaresultofprimaryorsecondaryadhesivecapsulitis.
TABLE 3
Diseases and Conditions Associated with Secondary Adhesive
Capsulitis
Diabetes mellitus
Thyroid illness
Trauma
Rheumatoid arthritis
Lung cancer
Pulmonary tuberculosis
Chronic lung disease
Myocardial infarction
Cerebrovascular accidents/hemiplegia
Scleroderma
Postmastectomy
Cervical radiculitis
Management
Althoughstudiescomparingvarioustreatmentmodalitiesforadhesivecapsulitisrevealthatno
specifictreatmentmethodhasanylongtermadvantage,earlyandaccuratediagnosisisimperative.
16
Inpatientswithadhesivecapsulitis,thegoaloftreatmentispainreductionandpreservationof
shouldermobility.Thefirststepispreventingsecondaryadhesivecapsulitisbydefinitivelyaddressing
underlyingcauses.Avoidingprolongedimmobilizationinpatientswhomaybepredisposedto
adhesivecapsulitisiscrucial.
Treatmentofashoulderinjuryofanyetiologyrequiresearlyrangeofmotiontherapytoreduce
musclespasmwhilemaintainingfullrangeofmotion.Heat,coldandothermodalitiesthatrelaxthe
musclesmayhelppreserverangeofmotion.Adequateanalgesiaisnecessaryforsuccessfultreatment
inthisphase.Vigorousandforcefulexercisesarecontraindicatedbecauseofthepainassociatedwith
theruptureofadhesions.Also,themorepainfultreatmentregimenshavebeenfoundtobeassociated
withahigherlevelofnoncompliance.Constantencouragementisnecessaryforpatientswithadhesive
capsulitis,sinceresolutionmaybeslow.Graduallyincreasingtherangeofmotionoftheshoulderwill
decreasethepainassociatedwiththedisease.Physicaltherapydoneathome,includingCodman
exercises,"climbingthewall"orplacingthingsuphighertoencouragereaching,iscosteffectivebut
requiresalongrehabilitativeprocess.
17
Nonsteroidalantiinflammatorydrugs(NSAIDs)helpto
relievepainandinflammation.Analgesicsareindicated
whenNSAIDsarecontraindicated.Musclerelaxantsare
helpfulintheearlystagesofthediseasewhenspasmis
predominant.Lowdoseantidepressantmedications
(e.g.,10mgofamitriptyline[Elavil]takenatnight)may
FIGURE 8. Anterior approach to
glenohumeral joint injection for adhesive
capsulitis.
helptoavoidacycleofsleepdisturbanceleadingtoa
chronicpainsyndromeandfibromyalgia.
8
Intraarticularcorticosteroidinjectionsareusedin
affectedpatientstorelievepainandpermitamorevigorousphysicaltherapyroutine.Theinjection
siteislocated1cmdistaland1cmlateraltothecoracoidprocess (Figure8).Fullexternalrotationof
18
thehumeruswiththeelbowheldinarelaxedpositionatthepatient'ssidehelpsopenupthespace,
whichisdifficulttoenterifcontractedbyadhesivecapsulitis. Theusualdosageis15to40mgof
19
triamcinoloneacetonide(Kenalog)oranotherdepotsteroidwith1mLof1percentlidocaine.
Althoughintraarticularcorticosteroidsarefrequentlyused,nolongtermbenefitsfromthistherapy
(i.e.,shortertimetofullrecovery)havebeenproved.Somecliniciansadvocatesimultaneousintra
articularandbursalinjectionsforpainreliefbeforebeginningphysicaltherapy.Oralcorticosteroids
arenothelpful.
Severeadhesivecapsulitisdiagnosedinthelaterstagesismoredifficulttomanage.Theabove
treatments,usefulonoccasion,arenotalwayssuccessful.Surgicalinterventionshouldbeconsidered
whenphysicaltherapyandinjectionsfail(noimprovementafterthreemonthsoftherapy).
Manipulationunderanesthesiatobreakuptheadhesionsisreservedforuseintheadhesivestage.
Duringthisprocedure,thejointcapsuleandsubscapularmusclesareruptured,andaggressive
rehabilitationisemployedtorestoreandmaintainrangeofmotionoftheshoulder.Patients
undergoingmanipulationmayreceiveanintraarticularcorticosteroidinjectionaftertheprocedure
andbeginphysicaltherapythedayoftheprocedure.Icingisoftenhelpful.
Anotheroptionistheadministrationofaninterscaleneblockbeforethemanipulation;thisrendersthe
patientpainfreeandallowsfortheimmediatestartofphysicaltherapy.Risksassociatedwith
manipulationunderanesthesiaincludehumeralfracture,
dislocationandrotatorcuffrupture.Contraindicationsto
manipulationincludesevereosteopenia,ahistoryof
fractureordislocation,orrecurrencefollowingadequate
manipulation. Forpatientswithlossofmotionrefractoryto
12
closedmanipulation,arthroscopiccapsularreleasehasbeen
showntoimprovemotionwithminimaloperativemorbidity. Inthisstudy,mostpatientshada
20
markeddecreaseinpain,andfunctionalimprovement.Someinvestigators demonstratedthat
21
arthroscopicreleasewashelpfulinpatientswithdiabetesassociatedadhesivecapsulitiswhowere
refractorytoconservativemeasures.Thirteenofthepatientsstudiedhadnopain,fullrangeofmotion
andfullfunctionaftersurgicalrelease.
Interestingly,amarkeddiscrepancyexistsbetweenthepatient'ssubjectiveawarenessofresidual
rangedeficitandthemeasurable(objective)restrictions.Manypatientswithrangedeficitsregard
theirrecoveryascomplete.Thisdifferenceinsubjectiveandobjectiveassessmentofrecovery,plus
thevariationandconfusioninthedefinitionsofadhesivecapsulitis,mayaccountfortheconflicting
reportsofprognosisandtherapy.
12
The Authors
LORIB.SIEGEL,M.D.,
ischiefoftheDivisionofRheumatologyatFinchUniversityofHealthSciences/ChicagoMedical
School,NorthChicago,Ill.SheisdirectorofundergraduateeducationintheDepartmentofMedicine.
Dr.SiegelreceivedhermedicaldegreefromtheMedicalCollegeofWisconsin,Milwaukee,and
completedaresidencyininternalmedicineandafellowshipinrheumatologyatGeorgetown
UniversityHospital,Washington,D.C.
NORMANJ.COHEN,M.D.,
isanorthopedicsurgeoninprivatepracticeandclinicalassistantprofessorintheDepartmentof
SurgeryatFinchUniversityofHealthSciences/ChicagoMedicalSchool.Heisalsoonstaffat
HighlandPark(Ill.)Hospital.Dr.CohenreceivedamedicaldegreefromAlbertEinsteinCollegeof
MedicineofYeshivaUniversity,Bronx,N.Y.,andcompletedtrainingingeneralsurgeryand
orthopedicsurgeryattheUniversityofIllinoisCollegeofMedicine,Chicago.
ERICP.GALL,M.D.,
isprofessorandchairmanoftheDepartmentofMedicineatFinchUniversityofHealth
Sciences/ChicagoMedicalSchool.Dr.Gallisalsoprofessorofimmunologyandmicrobiologyatthe
sameinstitution.HereceivedhismedicaldegreefromtheUniversityofPennsylvaniaSchoolof
Medicine,Philadelphia,wherehealsocompletedaresidencyininternalmedicineandafellowshipin
rheumatology.
Address correspondence to Lori B. Siegel, M.D., Division of Rheumatology, Finch University of Health
Sciences/Chicago Medical School, 3333 Green Bay Rd., North Chicago, IL 60064. Reprints are not
available from the authors.
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