Adhesive capsulitis of the shoulder

Adhesive capsulitis of the shoulder
Specialty	Rheumatology

Frozen shoulder, medically referred to as adhesive capsulitis, is a disorder in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, and grows together with abnormal bands of tissue, called adhesions, greatly restricting motion and causing chronic pain.

Adhesive capsulitis is a painful and disabling condition that often causes great frustration for patients and caregivers due to slow recovery. Movement of the shoulder is severely restricted. Pain is usually constant, worse at night, when the weather is colder, and along with the restricted movement can make even small tasks impossible. Certain movements can cause sudden onset of tremendous pain and cramping that can last several minutes.

This condition can last from five months to three years or more and is thought in some cases to be caused by injury or trauma to the area. It is believed that it may have an autoimmune component, with the body attacking healthy tissue in the shoulder. The condition may also cause chronic inflammation. Adhesions grow between the joints and tissue, greatly restricting motion and causing a number of painful complications. There is also a lack of fluid in the joint, further restricting movement.

Although the current aetiology of adhesive capsulitis is unknown, recent studies have indicated that adhesive capsulitis is possibly a manifestation of dysfunction in tissues involving the brainstem and spinal accessory nerve .

In addition to difficulty with everyday tasks, people who suffer from adhesive capsulitis usually experience problems sleeping for extended periods due to pain that is worse at night and restricted movement/positions, resulting in chronic fatigue and other complications. The condition also can lead to depression, pain, and problems in the neck and back, as well as damage to the surrounding tissue.

There are a number of risk factors for frozen shoulder, including diabetes, stroke, accidents, lung disease, connective tissue disorders, and heart disease. The condition very rarely appears in people under 40.

Treatment may be painful and taxing and consists of physical therapy, medication, massage therapy, hydrodilatation or surgery. A doctor may also perform manipulation under anesthesia, which breaks up the adhesions and scar tissue in the joint to help restore some range of motion. Physical therapy is very important at all stages of Adhesive Capsulitis, despite aggravating some amount of inflammation and pain, as it will prevent further loss of range and painful contracture. Pain and inflammation can be controlled with analgesics and NSAID's. If manual therapy and stretches are not applied, the shoulder capsule will continuously contract, leaving the shoulder with a severely restricted range of motion that is much more difficult to reverse.

People who suffer from adhesive capsulitis may have extreme difficulty working and going about normal life activities for several months or longer. If a diabetic patient develops the condition, the time to full recovery is often longer than the usual 12-month period.

Presentation

Movement of the shoulder is severely restricted. The condition is sometimes caused by injury that leads to lack of use due to pain but also often arises spontaneously with no obvious preceding trigger factor. These seemingly spontaneous cases are usually referred to as Idiopathic frozen shoulder. Rheumatic disease progression and recent shoulder surgery can also cause a pattern of pain and limitation similar to frozen shoulder. Intermittent periods of use may cause inflammation.

Abnormal bands of tissue (adhesions) grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally helps the shoulder joint move by lubricating the gap between the humerus (upper arm bone) and the socket in the scapula (shoulder blade). It is this restricted space between the capsule and ball of the humerus that distinguishes adhesive capsulitis from a less complicated, painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or who have been in an accident are at a higher risk for frozen shoulder. Adhesive capsulitis has been indicated as a possible adverse effect of some forms of highly active antiretroviral therapy (HAART).

The condition rarely appears in people under 40 years old and (at least in its idiopathic form) is much more common in women than in men (70% of patients are women age 40–60). Frozen shoulder in diabetic patients is generally thought to be a more troublesome condition than in the non-diabetic population and the recovery is longer.

Cases have also been reported after breast or lung surgery.

Prevention

To prevent the problem, a common recommendation is to keep the shoulder joint fully moving to prevent a frozen shoulder. Often a shoulder will hurt when it begins to freeze. Because pain discourages movement, further development of adhesions that restrict movement will occur unless the joint continues to move full range in all directions (adduction, abduction, flexion, rotation, and extension). Physical therapy helps with continued movement to discourage freezing and warm it.

Signs and diagnosis

With a frozen shoulder, one sign is that the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm. The movement that is most severely inhibited is external rotation of the shoulder.

People complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. A doctor or physical therapist may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can be diagnosed if limits to the active range of motion (range of motion from active use of muscles) are the same or almost the same as the limits to the passive range of motion (range of motion from a person manipulating the arm and shoulder). An arthrogram or an MRI scan may confirm the diagnosis, though in practice this is rarely required.

Physicians have described the normal course of a frozen shoulder as having three stages:

• Stage one: The "freezing" or painful stage, which may last from six weeks to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.

• Stage two: The "frozen" or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage generally lasts four months to nine months.

• Stage three: The "thawing" or recovery, when shoulder motion slowly returns toward normal. This generally lasts five months to 26 months.

Management

Management of this disorder focuses on restoring joint movement and reducing shoulder pain. Usually, it begins with nonsteroidal anti-inflammatory drugs (NSAIDs) and the application of heat, followed by gentle stretching exercises. These stretching exercises, which may be performed in the home with the help of a physical therapist. In some cases, transcutaneous electrical nerve stimulation (TENS) with a small battery-operated unit may be used to reduce pain by blocking nerve impulses.

The next step often involves one or a series of steroid injections (up to six) such as Methylprednisolone. Treatment may be needed for several months. Injections are usually given under radiological guidance, with either fluoroscopy, ultrasound or Computed Tomography (CT).  Radiological guidance is utilized so that the needle is safely and accurately guided into the shoulder joint.  Cortisone is injected into the joint in order to suppress the inflammation that is characteristic of this condition.  The shoulder capsule may also be stretched by also injecting normal saline, often to the point of rupturing the capsule in order to alleviate the pain and loss of motion due to its contraction.  The addition of saline in conjunction with the cortisone injection is known as hydrodilatation, or distension arthrography, however recent research has questioned the benefit of this additional component of the procedure given no statistical benefit than simply injecting cortisone alone.

If these measures are unsuccessful, the doctor may recommend manipulation of the shoulder under general anesthesia to break up the adhesions. Surgery to cut the adhesions (capsular release) may be indicated in prolonged and severe cases. The procedure is usually performed by arthroscopy. Surgery to correct other problems with the shoulder, e.g., subacromial impingement or rotatorcuff rupture may also be needed.

Alternative medicine treatments include:

• Acupuncture for pain management and greater range of movement
• Massage therapy
• Extensive streching after warming/heating up the shoulder on a daily basis
• Nutrition
• Osteopathy
• Water therapies, such as exercises in water, jacuzzi
• Chiropractic

See also

• Calcific tendinitis

References

This article contains text from the public domain document "Frozen Shoulder" , American Academy of Orthopaedic Surgeons, available from URL http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=162&topcategory=Shoulder.

External links

• "Frozen Shoulder" from the American Academy of Orthopedic Surgeons
• Siegel LB, Cohen NJ, Gall EP (1999). "Adhesive capsulitis: a sticky issue". Am Fam Physician. 59 (7): 1843–52. PMID 10208704. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
• Radiology image sequence demonstrating CT guided shoulder hydrodilatation