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Adhesive capsulitis

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Harry Sutton

on 5 October 2015

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Transcript of Adhesive capsulitis

Overview of Presentation
What is adhesive capsulitis?
Adhesive capsulitis is characterized by a painful, gradual loss of both active and passive glenohumeral motion
Structures involved
Jost et al (2000) completed an arthroscopic investigation and established that the structures primarily involved:

coracohumeral ligament
the rotator interval
(comprising of the
superior gleno-humeral ligament and the rotator interval capsule
anterior capsule

inferior glenohumeral ligament
These findings have been supported by similar investigations from Mengiardi et al. (2004) (n = 22), and Ozaki et al. (1989) (n = 5)
Further Description
What percentage of those affected will develop the condition in the opposite shoulder?
a) 5-10% b) 20-30% c) 50-60%
global loss of all gleno-humeral movements. In particular, loss of passive external rotation, both with the arm in neutral and in abduction (Guyver et al., 2014)
Symptoms & Behaviours
Past medical history
Objective assessment
It typically occurs in the 5th and 6th decades of life, thus affecting individuals of working age. It is rare before the age of 40 years and is unusual in patients over 70 years (Hand et al., 2007)
Frozen shoulder is estimated to affect 2–2.4% of the general population (Shah & Lewis, 2007)
A brief description of the condition, highlighting the pathophysiology and epidemiology
Underline what would be expected within a subjective Ax (Onset & Duration, Symptoms, Site & Spread, Past Medical History, Risk Factors)
Highlight what would be discovered during an objective examination?
Discuss the available evidence-based treatments
Frozen shoulder can be classified as either
(idiopathic – as in there are no detectable underlying cause) or
(traumatic or immobilisation; American Shoulder & Elbow Surgeons, 2012 )
Secondary types are associated with numerous soft tissue and medical pathologies including
rotator cuff injuries,
impingement syndrome,
traumatic arthritis,
shoulder joint immobilization
and diabetes
1. The condition comes on slowly
2. Pain is felt near the insertion of deltoid, but also diffusely around the shoulder
3. Inability to sleep on the affected side
4. Painful and incomplete elevation
5. Limited external rotation
Shoulder injuries; Slap tear (Glenoid labrum), shoulder impingement .

Diabetics have a 2–4 times greater risk and a 10–20% life-time risk of developing frozen shoulder compared to the general population (Dias et al., 2005)

Patients who have a cerebrovascular accident or a myocardial infarction have been reported to be at increased risk (Miller et al., 1996)

6 hours of intensive supervised training
The ASES (2010) and BESS (2012) collectively agreed that secondary diabetic frozen shoulder being considered as a separate type since their disease course is usually more severe and protracted.

Described as a
fibrotic inflammatory contracture of the rotator interval, capsule and surrounding ligaments
(Guyver et al., 2014)
Caused by the thickening and inflammation of the joint capsule and the soft tissue surrounding the gleno-humeral joint
From these findings its been concluded that Frozen Shoulder is not considered a boney issue, but in fact a soft tissue one (Guyver et al., 2014).
CHL = external rotation in neutral
MGHL = external rotation in mid-elevation
AIGHL = external rotation in abduction
Inferior capsule (ICS) = abduction in neutral rotation
PIC = internal rotation
PSC = internal rotation in abduction

The capsule is thickened and inflamed with vasculitic‘frond’ like projections (villonodular synovitis) in the rotator interval
Patients suffering from this condition face months to years of pain and disability
Definition difficulties
There has been an acknowledgment of the absence of a specific definition and of diagnostic criteria frozen shoulder (British Elbow & Shoulder Society; BESS, 2012)
BESS have tried to improve on the long established definition of Codman (1934) who described the common features of frozen shoulder as:
a slow onset of pain felt near the insertion of the deltoid muscle,
inability to sleep on the affected side
with restriction in both active and passive elevation and external rotation,
yet with normal radiographic appearance.
Following a survey in 1998, the BESS agreed with the following definition and diagnostic criteria.
Women are marginally more affected than men (Guyver et al., 2014)
Subjective Assessment
Onset & duration:- Clinical presentation is classically in three overlapping phases:
Phase 1 (Freezing): Lasting 2–9 months; Painful phase or pain predominant phase, with
progressive stiffening and increasing pain on movement

Phase 3 (Thawing): Lasting 12–42 months; Resolution or thawing phase,where there is
improvement in range of motion with resolution of stiffness
Phase 2 (Frozen): Lasting 4–12 months; Stiffening, freezing or stiffness pre-dominant phase, where there is
gradual reduction of pain but stiffness persists with considerable restriction in range of motion

Aetiology & Pathophysiology
Histological studies of the capsule have confirmed significant increases in collagen (type 3), fibroblasts, myofibroblasts and inflammatory cells including mast cells, T cells, B cells and macrophages (Hand et al., 2007)
These findings suggest a combination of chronic inflammation and proliferative fibrosis, supporting the theory that this is both a chronic inflammatory and a fibrotic condition
The presence of T cells and B cells suggest the cause of frozen shoulder could be an autoimmune response (Hand et al., 2007), however other research has been contradictory (Hannafin, 2010).
Ischemia:- Cause local release of free radicals and a platelet-derived growth factor & TGF-beta that can initiate a cycle of fibroblastic hyperplasia and excessive deposition of collagen (Bunker, 1995)
6. Limited active and passive movement
7. Atrophy of the rotator cuff muscles
9. Little local tenderness
I0. X-rays negative except for bony atrophy
11. Trouble continuing their daily habits and routines. Brushing their hair and reaching for objects.
Pain from the
acromioclavicular joint is common
, as the restricted glenohumeral movement increases the stress on this joint
Family History
Genetic link with twins having up to a threefold increased risk (Hakim et al., 2003)
Previous frozen shoulder (Guyver et al., 2014)
Objective assessment
Most clinicians would agree that external rotation should be reduced by more than 50% compared to the unaffected side to consider a diagnosis of frozen shoulder (Guyver et al., 2014)
Strength assessment
:- According to Norris (2004), isometric strength testing should not cause any pain.
Reported loss of strength due to disuse atrophy of the rotator cuff muscles (Norris, 2004).
Special tests
:- Examination tests for other shoulder abnormalities can also be positive:
Testing for impingement may be positive with a Hawkin’s or Neer sign; however, the pain is likely from the intrinsic process of impingement or capsular stretch
Positive result from shrug sign (Hegedus, 2012)
:- An area of pinpoint tenderness is rarely found (Siegel et al., 1999)
Non-operative treatment
Nonsteroidal anti-inflammatory drugs (NSAIDs)
. Despite their widespread use, literature on NSAIDs for the treatment of adhesive capsulitis is limited.
Oral steroid treatment
. A systematic review in 2006 identified five RCTs, which indicated that oral steroids provide improvements in pain, range of movement and function but only for a period of less than six week (Buchbinder et al., 2010).
Severe limitations within this systematic review. Authors of all RCTs had professional gains from promoting oral steroids. RCTs were of poor quality. Steroids were used in conjunction with other treatments
Intra-articular corticosteroid injections:
given to help reduce inflammation and provide analgesia.
Non-operative treatment
While their use has been evaluated in several RCTs, a criticism of most trials is that steroid injection was frequently administered in combination with other treatments (Guyver et al., 2014)
Bulgen et al. (1984) randomized 42 patients to 1 of 4 treatment (1) intra-articular injection (2) mobilization with a physiotherapist, (3) ice treatments following proprioceptive exercises, and (4) no treatment.
Those treated with steroid injections had the most marked improvement in range of motion at 4 weeks’ time
Operative treatment
Manipulation under anaesthetic
The capsule of the gleno-humeral joint is deliberately torn by controlled manipulation of the arm through a specific sequence of movements
Complications of this technique have been reported including humeral fracture, subscapularis rupture, labral tears, and injury to the biceps tendon
Evidence to support MUA remains limited with very few high quality studies (Guyver et al., 2014).
Kivimaki et al (2007) compared MUA with a home-based exercise program (n=125)
The manipulation group had slightly better mobility at 3-month follow-up examinations with statistically significant improvement in shoulder flexion
Inclusion criteria was not limited to patients who had failed conservative treatment
Operative treatment
Arthroscopic capsular release
begins with an arthroscopic inspection of the gleno-humeral joint to confirm the diagnosis
The contracted structures ofthe rotator interval (coracohumeral ligament, anterior capsule,superior and middle gleno-humeral ligaments) are then released using radio-frequency ablation.
Prolonged recovery, postsurgical stiffness, and restricted postoperative therapy
Operative treatment
Arthroscopic capsular release
: Omari & Bunker (2001) treated 25 patients who had failed nonoperative measures with an open excision of the rotator interval.
Pain and range of motion improved in all directions.
However, of the 7 patients in the study who had diabetes mellitus, 4 had poor results
The evidence to support this intervention is still limited. There are no RCTs or comparative studies involving arthroscopic capsular release

Stage depending
:- most consistently prescribed treatment to prevent capsular contracture and to improve motion in the latter stages of disease (Guyver et al., 2014)
Patient Education
:- educated in the chronicity of this condition. apprehension and a feeling of urgency for functional return may be decreased (Norris, 2004)
A six- to twelve-week course of physiotherapy is commonly pre-scribed for many patients suffering with shoulder pain with the aim of improving limitations in range of movement
Simple shoulder movements (pendular swings) and grade 1 & 2 mobilisation during aggressive stages (Norris, 2004)
Physiotherapy CTD
Later Stages:- involve grade 3 & 4 passive mobilisation, capsular stretching (sleeper's stretch), and more functional exercises retraining movement.
Strengthening exercises
ROM exercises
Shoulder class
Griggs et al. (2001) prospectively evaluated 75 patients with stage 2 disease treated with a specific 4-direction stretching program. Stretching was limited to the range of tolerable discomfort
Outcome measures:
assessment of pain, range of motion, and function
completion of the Short Form-36 (SF-36) Health Survey
active forward elevation increased 43 degrees, active external rotation increased 25 degrees, passive internal rotation increased eight vertebral levels, and the glenohumeral rotation arc at 90 degrees of abduction increased 72 degrees (p < 0.00001).
Physical therapies (viscoelastic properties of the connective tissue)
Sixty-four (90 percent) of the patients reported a satisfactory outcome, and pain significantly improved.
Combination of physiotherapy and another treatment
Quality of evidence
Treatment of Frozen Shoulder
Hand et al., (2007) completed follow up. 35% of patients complained of pain & stiffness
Later Stages
Carette et al., (2003)
Systematic review by Maund et al. (2012)
Economic evaluation of treatments
Role of the physiotherapist
Bulgen, D. Y., Binder, A. I., Hazleman, B. L., Dutton, J., & Roberts, S. (1984). Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens. Annals of the rheumatic diseases, 43(3), 353-360.

Buchbinder, R., Green, S., Youd, J. M., & Johnston, R. V. (2006). Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev, 4.

Bunker TD, Anthony PP. The pathology of frozen shoulder. A Dupuyten-like disease. J Bone Joint Surg Br. 1995;77:677–83.

Carette, S., Moffet, H., Tardif, J., Bessette, L., Morin, F., Frémont, P., ... & Blanchette, C. (2003). Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: A placebo‐controlled trial. Arthritis & rheumatism, 48(3), 829-838.

Dias, R., Cutts, S., & Massoud, S. (2005). Frozen shoulder. BMJ: British Medical Journal, 331(7530), 1453.

Griggs, S. M., Ahn, A., & Green, A. (2000). Idiopathic Adhesive Capsulitis A Prospective Functional Outcome Study of Nonoperative Treatment*. The journal of Bone & Joint Surgery, 82(10), 1398-1398.

Guyver, P. M., Bruce, D. J., & Rees, J. L. (2014). Frozen shoulder–A stiff problem that requires a flexible approach. Maturitas, 78(1), 11-16.

Hand, G. C. R., Athanasou, N. A., Matthews, T., & Carr, A. J. (2007). The pathology of frozen shoulder. Journal of Bone & Joint Surgery, British Volume, 89(7), 928-932.

Hegedus, E. J., Zavala, J., Kissenberth, M., Cook, C., Cassas, K., Hawkins, R., & Tobola, A. (2010). Positive outcomes with intra-articular glenohumeral injections are independent of accuracy. Journal of Shoulder and Elbow Surgery, 19(6), 795-801.
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