Shoulder and Elbow cases adhesive capsulitis

A 57-year-old, right-hand-dominant female presents with left shoulder pain and stiffness for the last 3 months. She has a history of diabetes, hypothyroidism, and breast cancer. She reports having difficulty sleeping on her left side. She localizes her pain over the deltoid insertion. The stiffness has become worse. The pain has been improving over the last 3 weeks but is exacerbated by extreme left shoulder motion. She is having difficulty dressing and combing her hair. She works as a statistical analyst and sits at a desk most of the day. On physical examination, she has normal strength with left shoulder abduction and external rotation, a negative cross-body adduction test, and no pain with a supinated O’Brien’s test. An x-ray is obtained and shown in Figure 2–76.

 

 

 

Figure 2–76

 

Of the following, what is the most likely diagnosis of this patient?

1. Rotator cuff tear

2. Calcific tendinitis

3. Acromioclavicular joint arthritis

4. Adhesive capsulitis

5. Glenohumeral joint arthritis

 

Discussion

The correct answer is (D). Adhesive capsulitis (AC) is a specific pathologic entity that produces subsynovial chronic inflammation resulting in capsular thickening, fibrosis, and adherence of the capsule to itself and the anatomic neck of the humerus. The thickened and stiff capsule causes pain and a restraint to motion. This is called primary, or idiopathic, AC. The remaining answer choices are incorrect and can result in symptoms similar to those of AC (i.e., loss of shoulder motion and pain), but their underlying etiology is different. It is important to recognize that all these conditions can cause a stiff and painful shoulder (a “frozen shoulder”) but is not necessarily AC. AC occurs more frequently in sedentary females in the non-dominant hand, and has been associated with diabetes mellitus, thyroid dysfunction, breast cancer treatment, cardiovascular disease and cerebrovascular disease.

The patient is diagnosed with stage 3 adhesive capsulitis. On physical

examination, which of the following is the most likely to be found?

1. Decreased passive and active range of motion of the shoulder in all planes

2. Decreased passive and active range of motion of the shoulder in external rotation

3. Pain with passive and active range of motion of the shoulder

4. Pain with resisted forward flexion of the arm

5. Pain with external rotation of the arm

 

Discussion

The correct answer is (A). A “frozen shoulder” results from a known intrinsic, extrinsic, or systemic cause that may result in a global or partial loss of shoulder motion. However, adhesive capsulitis (AC) is idiopathic and always results in a global loss of passive and active range of motion. Answer B would likely result from a known cause, such as an excessively tight anterior soft-tissue repair for instability. Answers C, D, and E are all associated with pain during motion. This would be expected in the early stages of AC, but due to patient’s reported decreasing pain, these answer choices can be eliminated. Table 2–11 lists the stages of AC. The diagnosis and staging is made clinically. The table provides a description of the arthroscopic and histopathologic appearances. An intra-articular anesthetic injection can be used to distinguish stages 1 and 2.

 

Table 2–11 STAGES OF ADHESIVE CAPSULITIS

 

	Symptoms	Signs	Arthroscopic Appearance	Biopsy Appearance
Stage 1	Pain referred to the deltoid insertion	Capsular pain on deep palpation	Fibrous synovial inflammatory reaction	Rare inflammatory cell infiltrate
Stage 2	Pain at night   Severe night pain   Stiffness	Empty end feel at extremes of motion   Full motion under anesthesia Motion restricted in forward flexion, abduction, internal and external rotation Some motion loss under anesthesia	No adhesions or capsular contracture   Christmas tree synovitis   Some loss of axillary fold	Hypervascular, hypertrophic synovitis Normal capsular tissue Hypertrophic, hypervascular synovitis   Perivascular, subsynovial capsular scar
Stage 3	Profound stiffness	Significant loss of motion	Complete loss of axillary fold	Hypercellular, collagenous tissue with a thin

Stage 4	Pain only at the end of range of motion   Profound stiffness	Tethering at ends of motion No improvement under anesthesia Significant motion loss	Minimal synovitis   Fully mature adhesions	synovial layer Similar features to other fibrosing conditions   Not reported
	Pain minimal	Gradual improvement in motion	Identification of intra-articular structures difficult

 

What is the most appropriate treatment for this patient’s shoulder problem?

1. Arthroscopic capsular release

2. Physical therapy (PT) with a home exercise program (HEP)

3. Intra-articular corticosteroid injection

4. Manipulation under anesthesia (MUA)

5. Aggressive physical therapy working on strengthening and range of motion

 

Discussion

The correct answer is (B). Regardless of the stage, initial nonoperative treatment is appropriate for adhesive capsulitis. The natural course has been described as self-limited and improves over a 24-month period. However, there are no true natural history studies in the literature without intervention given. The reported outcomes of minimally treated patients vary considerably, therefore patients should be treated focusing on recovery of motion and decreasing pain. PT with HEP is the mainstay of treatment. PT does not need to be aggressive and strengthening exercises are not necessary. Nonsteroidal anti-inflammatory drugs in addition to oral and intra-articular steroid injections are often combined with PT. Intra-articular corticosteroid injections appear to provide early pain relief, but this has not been shown to change the long-term outcome.

More aggressive treatments include MUA and arthroscopic or open capsular release, however, no specific indication guidelines exist. MUA and surgical treatment should not be considered when the patient is experiencing severe pain in addition to loss of motion because this may represent the inflammatory stage of the disease and could exacerbate the motion loss by increasing capsular injury. Answer D is incorrect because MUA would be utilized only after PT has failed. Some recommend an MUA prior to or as an adjunct to capsular release. The technique of MUA is critical to ensure the inferior capsule is released from the humerus without the complications of humeral fracture or rupture of the subscapularis. Arthroscopic capsular release has supplanted MUA at many institutions. Open capsular release can

be considered if arthroscopic release is not successful or if aberrant anatomy prevents visualization of the appropriate structures arthroscopically. Other, less investigated forms of treatment include suprascapular nerve blocks, hydrodilation, and extracorporeal shockwave therapy.

After 12 months of being compliant with her home exercise program and undergoing multiple steroid injections, the patient continues to have difficulty with her range of motion and is not happy with her shoulder function. She is inquiring about other treatment options.

When taking into account surgical options for this patient, arthroscopic release of the anterosuperior capsular region and the rotator interval will most likely result in what improved motion?

1. Abducted external rotation of the arm

2. Adducted internal rotation

3. Adducted external rotation

4. Abduction in neutral rotation

5. Forward flexion in the scapular plane

 

Discussion

The correct answer is (C). The limitation of external rotation of the adducted shoulder is associated with contracture of the anterosuperior capsular and rotator interval. Release of this area would increase adducted external rotation. Releasing the anteroinferior capsule would increase abducted external rotation. Adducted internal rotation range of motion would be increased with posterior capsule release. Abduction in neutral position and forward flexion can be increased with MUA. The outcomes are generally good with arthroscopic treatment of AC, but close followup is required. A long recovery and rehabilitation period can be expected.

 

Objectives: Did you learn...?

 

Recognize a patient with adhesive capsulitis based on history and physical examination findings?

 

Understand the basic pathogenesis of adhesive capsulitis?

 

Appropriately stage adhesive capsulitis based on history and physical examination findings?

 

Treat adhesive capsulitis appropriately with either conservative or operative approaches?

 

Understand the outcome and prognosis of adhesive capsulitis?