Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Adhesive Capsulitis

Key Points

  • True shoulder stiffness is the loss of passive range of motion in the shoulder.
  • Many patients who complain of stiffness do not have true shoulder stiffness. Rather, they have pain and inflammation, and because movement results in discomfort, they guard against painful movement and appear to have lost range of motion.
  • Stiffness arising out of adhesive capsulitis is a primary and idiopathic condition due to intrinsic changes within the glenohumeral joint capsule. These changes result in thickening and contracture of the capsule.
  • The working definition of adhesive capsulitis is “a condition of uncertain etiology characterized by significant reduction of both active and passive shoulder motion that occurs in absence of a known intrinsic shoulder disorder.”
  • Adhesive capsulitis is commonly observed in patients during their fifth and sixth decades, with an incidence of 2% to 5% in this age group, and a greater frequency in women. There is an increased occurrence in patients having suffered closed head injuries, Parkinson disease, autonomic disorders of the upper extremity, and diabetes mellitus.
  • Adhesive capsulitis typically progresses through three clinical phases—the initial inflammatory phase, the proliferative or “freezing” phase, and the “thawing” phase, characterized by resolution of painful contracture.
  • Patients with adhesive capsulitis have a global reduction in range of motion with a marked decrease in glenohumeral translation. Examination of the opposite shoulder (if normal) is performed to identify the patient’s expected range of motion.
  • Evaluation is not complete without an appropriate series of plain radiographs. True glenohumeral anterior-posterior views, along with axillary, scapular outlet and acromioclavicular views, are necessary to exclude other shoulder girdle conditions.
  • Nonoperative treatment commonly begins with measures to reduce pain and inflammation. The mainstay of treatment is administration of range of motion stretching exercises. Medication is also used.
  • Because adhesive capsulitis is due only to a tight and thickened glenohumeral capsule, arthroscopic surgery seems ideal for treatment. The capsule is best viewed, and more directly surgically addressed, by an intra-articular approach.

It is common for patients to present to orthopaedic surgeons with complaints of shoulder stiffness. Many of these patients, although they initially appear to have limited range of motion, do not have true shoulder stiffness. Instead, they have pain and inflammation in the shoulder girdle, and because shoulder movement results in discomfort, they guard against the painful movement, only appearing to have lost range of motion.

In other patients, stiffness may be confused with a decreased ability to produce active range of motion. Although these individuals are limited in the active mobility of their shoulder due to weakness, they have no joint contracture and have normal passive range of motion.

A smaller group of patients present with true shoulder stiffness—the loss of passive range of motion in the shoulder. True shoulder stiffness can be a primary condition arising
independent of any other abnormality or illness (so called idiopathic stiffness), it can be a primary condition arising in conjunction with another medical condition (such as diabetes mellitus), or it can develop secondary to another condition (such as prior surgery, arthritis, or trauma).

The stiffness arising out of adhesive capsulitis is a primary and idiopathic condition due to intrinsic changes within the glenohumeral joint capsule. These changes result in thickening and contracture of the capsule, which is often painful. This condition may be persistent and difficult to endure. Treatment of these patients is often challenging and their recovery may be limited as described by Simmonds who wrote in 1949, “Complete recovery … is not my experience.”

DePalma agreed when he wrote, “It is erroneous to believe that in all instances restoration of function is attained.” Patients who develop shoulder stiffness associated with other conditions such as diabetes may appear to have adhesive capsulitis. Both of these conditions arise out of a primary capsular contracture, so they display great similarity in their presentation and development.

Treatment for these patients, although similar, can be more difficult due to the additional dimension of medical illness present. In some cases, stiffness associated with another medical condition is more resistant to treatment than adhesive capsulitis.

Treating patients with shoulder stiffness arising secondary to other abnormalities (such as prior surgery, arthritis, or trauma) is often challenging as well. To regain range of motion in these patients, the orthopaedist often must address not only any capsular contracture present, but he or she must also treat the primary abnormalities of intra-articular deformity or extra-articular scarring to improve the patient’s function. This chapter will focus its attention mostly upon the characteristics and treatment of adhesive capsulitis.

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