Adhesive capsulitis of the shoulder, also known as frozen shoulder, is a condition characterized by thickening and contraction of the shoulder joint capsule and surrounding synovium. Adhesive capsulitis can rarely affect other sites such as the ankle 8.
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Epidemiology
The incidence in the general population is thought to be 3-5%. Adhesive capsulitis typically affects women in their 5th to 6th decades, although patients with co-morbidities such as diabetes mellitus 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
The characteristic symptom is shoulder pain and associated with it a painfully limited range of motion. The pain also occurs at night, which negatively affects sleep quality 22.
Adhesive capsulitis presentation can be broken into three distinct stages:
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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 acute synovitis of the glenohumeral joint
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frozen: transitional stage
most patients will progress to the second stage
during this stage, shoulder pain does not necessarily worsen
because of pain at the end of the range of motion, arm movement 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
a point is eventually reached in the frozen stage where pain does not occur at the end of the range of motion
-
thawing stage
begins when the range of motion starts 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
Fluoroscopy
Described features of fluoroscopic arthrography 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
limited external rotation, identified when positioning for subscapularis tendon assessment
thickened coracohumeral ligament (CHL) can be suggestive 9
thickening of the inferior glenohumeral capsule 16
hypoechoic soft tissue around the long head of biceps at rotator interval 13,20
increased vascularity of the long head of the biceps at rotator interval 13,20
MRI/MR arthrography
The signs of adhesive capsulitis are variable with some but rarely all of the following expected to be present:
T2 hyperintensity of the inferior glenohumeral ligament on T2 fat-saturated sequences 17,19
coracohumeral ligament thickening >4-7 mm 4,19
-
joint capsule thickening 2
anterior capsule thickness >3.5 mm and abnormal hyperintensity 14
axillary pouch thickening >3-4 mm has been specicic for adhesive capsulitis in some studies 1,2,5 but not in others 3,4,17-19
abnormal soft tissue thickening within the rotator interval with signal alteration 18
abnormal soft tissue encasing the biceps anchor 18
variable capsular and synovial enhancement within the axillary recess and rotator interval 18
distention of the subscapular recess is very suggestive 21
Chronic frozen shoulder may show low T2 signal and pericapsular scarring 15.
Treatment and prognosis
Adhesive capsulitis is typically a self-limiting disease that improves over 1-2 years. Treatment options include:
physiotherapy
corticosteroid injections
closed manipulation under anesthesia
arthroscopic capsular release with lysis of adhesions