ADHESIVE CAPSULITIS
THANATHEP TANPOWPONG
ASSISTANT PROFESSOR
CHULALONGKORN UNIVERSITY
“difficult to define
difficult to treat
difficult to explain”
Codman
• Codman first define “frozen shoulder”
• 1945 : Nevaiser describe pathological lesion of
fibrosis, inflammation and capsular
contracture
Prevalence
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2-3% of population (Female)
40-60 year
Non-dominant hand
20-30% involve opposite side
Etilogy
• Unknown
– Trauma
– Inflammation (TGF-β)
– Associate with diabetes, thyroid dysfunction,
Dupuytrens contracture, autoimmune disease,
treatment of breast cancer, cerebrovascular
accident, MI
Diagnosis
• Primary : idiopathic process, global capsular
inflammation and fibrosis
• Secondary : known injury or disesase prior to
adhesion
62% of idiopathic adhesive capsulitis were
found to have partial thickness tear of
supraspinatus
Yoo et al Orthapaedics. 2009;32(1):22
Staging (Neviaser et al CORR 1987)
Symptom
1 pain
Sign
Finding
Full ROM under GA
synovitis
2 Severe night
Stiff (external rotation)
pain, early stiff
Christmas
tree synovitis
3 Stiff, pain at
Significant loss motion
end of motion
Minimal
synovitis,loss
axillary fold
4 Profound stiff, Motion loss but start to Difficult to
minimal pain improve
identify joint
• Stage 1
– Pain, stiff
– Gain full ROM after GA or intra-articular
anesthetic injection
– Duration 3 month
• Stage 2 (freezing)
– Progressive capsular contracture
– Limit ROM (not fully recovered)
– “Christmas tree appearance”
Acknowledgement to Neviaser AMJ Sport 2010;38:2346
• Stage 3 (frozen)
– Progressive loss of motion
– Not improve after intraarticular anesthetic
injection
– Duration 9-15month
• Stage 4 (thawing)
– Minimal pain
– Gradual improve ROM
– Fully mature adhesion
– Difficult to identify intra-articular structure during
arthroscope
Natural history
• No true study of natural history
• Self-limiting
• Grey: complete recovery in 2 years
JBJS Am 1978;60(4):564
• Miller: normal function and minimal pain after
home therapy 4 year after home therapy
Orthopaedics 1996;19(10):849-853
• 94% of idiopathic frozen shoulder recover to
normal level, range of motion, function
without treatment
Vastamaki et al CORR 2012;470(4):1133.43
TREATMENT
• Address underlying pathology
• Treatment according to clinical stage at
presentation
NSAIDs
• Theoretical benefit
• No level I or II study to prove effectiveness
• Improve pain but not improve motion
Rhind Rhumatol Rehabil 1982;21(1):51-53
Duke Rhumatol Rehabil 1981;20(1):54-59
• Cox-2 have comparable efficacy compare to
Cox-1 ( better night pain control)
Otha et al. Mod Rhumatolol. Feb 2013
Oral steroid
• Provide rapid relief of pain (similar to
intraarticular steroid injection) but not sustain
at long term
Buchbinder Ann Rhum Dis 2004;63(11):1460-1469
• Possible long term systemic effects
• Not recommend
Intra-articular steroid injection
• Rizk et al : transient (2-3 week) improvement
of pain compare to placebo
Arch Phys Med Rehabil 1991;72(1):20-22
• Bulgen et al : improve pain and motion in 4
weeks
Ann Rheum Dis 1984;43(3):353-360
• Van der Windt
– 109 patient
– 40 mg of triamcinolone vs physical therapy 2/wks
– 2.2 injection/6 weeks
– Passive joint motion, exercise, ice, hot,
electrotherapy
– 1 year follow up
– Self-assessment and functional score
– 77% success in injection group vs 46% in physical
therapy group
BMJ 1998;317(7168):1292-1296
• Intraarticular steroid injection gives better
result in early stage of disease
• Stage 1recover in 6 weeks
• Stage 2 recover in 7 months
Marx HHS J 2007;3(2):202-207
Physical therapy
• Most consistently prescribe for latter stage
• Cochrane database review
– Little overall evidence (4/26)
– No evidence that physiotherapy alone is of benefit
in adhesive capsulitis
Cochrane Database Syst Rev 2003;(2):CD004258
• Carette and Bulgen found no difference
between physiotherapy and no treatment
(control group)—level I study
– Low number of participants
Arthritis Rheum 2003;48(3):829-838
Ann Rhum Dis 1984;43(3):353-360
• Level I study by Vermeulen
– Low grade mobilization have little difference
compare with high grade technique
– Low grade : movement with in pain free zone
– High grade: movement into stiff and painful range
– “reflex muscle acivity”
Phys Ther 2006;86(3):355-368
Surgical intervention
In most series 10% of patients do not respond to
non-operative treatment
Surgical intervention
1. Suprascapular nerve blocks
2. Hydrodilation
3. Manipulation under
anesthesia
4. Arthroscopic release
5. Open release
• Suprascapular nerve block
– Unclear therapeutic mechanism
– Disruption of efferent and afferent pain signaling
– May normalization pathological and neurological
process
– Insufficient data to prove it’s efficacy
• Hydrodilation (Brisement)
– Increase intracapsular pressure until rupture
– Compare hydrodilation with MUA
• No diiference in ROM
• Better Constant and VAS score
Quraishi JBJS Br. 2007;89(9):1197-1200
– Small number of trials to proof it’s efficacy
Manipulation (MUA)
• MUA vs home exercise (level II)
– Slight better moblility at 3 month
– No difference in 6 and 12 month
Kivimaki J Shoulder Elbow Surg 2007;16(6):722-726
• MUA have effect of improve motion and pain
relief for approx 23 years
CORR 2013;471(4):1245-50
Arthroscopic release
• Advantage
– Accurate and complete
– Ability to perform synovectomy
– Improve mobility of musculotendinous unit
compare with open surgery
– Minimal pain
– Identify intrinsic pathology
– Post operative motion can be done immidiately
• Contraindication
– Unable to cooperate postoperative program
– Pateint cannot tolerate stress from fluid challenge
(renal or cardiac failure)
Surgical technique
Release rotator interval , SGHL
MGHL
Posterior capsular release
Release axillary pouch and IGHL (multiple
perforation or direct cut)
My practice
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Stage 3 or 4
No intraarticular steroid are injected
Jackin’s exercise (low grade)
Nsaids prior and ice after
If 3-6 month not improve MUA or scope
release
Jackin’s exercise program
• Each 4 position are perform 10 times/round
• 5 round/day
• Post operative protocol
– Regional nerve block ( interscalene, SSN, brachial)
– Immediate post-op : pendulum exercise
– Passive stretching ( Forward flexion, IR, ER, ABD)
– 2 times/day, 15 minutes/session
– Follow up: post-op week 1,2,4,6,8
Thank you