PT Tip of the Month Archive

Adhesive Capsulitis

The glenohumeral (shoulder) joint is a ball and socket joint. The ball, or humeral head, derives from the top end of the upper arm bone known as the humerus. The socket, also known as the glenoid fossa, is the outer portion of the scapula. Together, they form the very shallow joint of the shoulder. The shallow shape of the joint allows the shoulder to be the most mobile joint in the body, permitting us to reach overhead, to the side, behind our back, and much more.

However, to provide stability to this extremely mobile joint, we rely on a number of soft tissues such as muscles, cartilage, and ligaments. The joint capsule, which is a part of all our joints, is a fibrous membrane that completely encloses the joint. Dysfunction of this tissue causing inflammation and tightness can result in a very painful and debilitating disorder known as adhesive capsulitis (frozen shoulder).

Anatomy

Shoulder anatomyThe joint capsule runs from the outer rim of the glenoid fossa to the neck of the humerus. This tissue acts as a passive restraint to assist in prevention of shoulder dislocation. However, the joint capsule is a very loose tissue, preventing restrictions to the large mobility of the shoulder. Just outside of this membrane lies the superior, middle, and inferior glenohumeral ligaments. These three bands run along the joint capsule to provide greater support to the anterior (front) aspect of the joint. When this capsule becomes inflamed, the tissue stiffens, thickens, and adheres down. This results in pain, limited shoulder mobility, and impaired function.

Causes

Frozen shoulderAdhesive capsulitis is primarily considered an idiopathic disorder. This means the causes are not yet fully understood or defined. There are however a few factors that may increase the risk of developing this condition. Adhesive capsulitis occurs more often in patients with diabetes. While the reason for this is unknown, 10 to 20% of this population is affected. This can also occur after long periods of immobilization such as injuries requiring slings or limiting motion, shoulder fractures, or orthopedic surgeries of the shoulder. Early mobilization of these patients can help to prevent occurrence. Other medical ailments associated are thyroid disorders, rheumatic disorders, cardiac disease, and Parkinson's disease. Additionally, while they are not causes, adhesive capsulitis more commonly affects those ages 40 to 60, and occurs in women more than men.

Symptoms

The most noted symptom of adhesive capsulitis is progressively limited movement of the shoulder. The classic presentation of this condition presents in three stages taking up to a couple years to fully resolve. The first stage is the "freezing" stage. Here, pain gradually increases. As the pain becomes more severe the shoulder begins to lose range of motion. Patients frequently complain of difficulty laying on the affected shoulder or sleeping, and avoid using the arm to reduce pain. This stage can last anywhere between six weeks to nine months. The second phase is the "frozen" stage. In this stage pain may begin to subside but stiffness remains and plateaus. The primary complaint of patients during this four to six month stage is related to impaired daily activities such as dressing, reaching into cabinets, or brushing hair. The final stage, which can take between six months to two years, is known as the "thawing" stage. Patients will note little to no pain and gradual return of movement. Complete or near full recovery of motion is reported in most cases.

Diagnosis & Treatment

Unfortunately, diagnostic imaging such as X-rays and MRIs do not help to rule in adhesive capsulitis as a diagnosis. However, these studies can help doctors to rule out other causes to shoulder pain and stiffness such as rotator cuff tears or fractures. The best way to diagnose adhesive capsulitis is with a physical exam. Once your health care provider has finished asking you questions regarding your symptoms and medical history, they will begin to look at the shoulder's motion, both actively and passively. These measurements will be compared to your unaffected shoulder. Classically with adhesive capsulitis, external rotation (rotating the arm away from the body) is most limited, followed by abduction (move the arm out to the side), then internal rotation (rotating the arm towards the body). This is known as the capsular pattern of the glenohumeral joint.

Physical therapy imageOnce diagnosed, many patients are referred to physical therapy. Physical therapists use joint mobilizations to help gently stretch the joint capsule, as well as range of motion exercises, to facilitate the return of motion. Patients typically are advised to follow a home program of exercises to optimize on recovery. Due to the degree of limited movement from this disorder and the inability to use the joint, strength is often lost with time. As motion begins to return, the physical therapist will tailor your exercise regime to include strengthening of the upper back, rotator cuff, and shoulder. These conservative treatments have been shown to improve greater than 90% of patients. For those with persistent pain or dysfunction, cortisone injections into the shoulder can help to alleviate pain. In rare cases, surgery will be performed to cut through the adhered portions of the joint capsule.

If you feel that you have signs or symptoms of adhesive capsulitis, and you would like to schedule an evaluation, call 617-232-PAIN for our Brookline office, and 617-325-PAIN for our West Roxbury office.

33 Pond Avenue, Suite 107B Brookline, MA 02445 Tel: (617) 232-PAIN (7246) Fax: (617) 232-5196
1208B VFW Parkway, Suite 202 West Roxbury, MA 02132 Tel: (617) 325-PAIN (7246) Fax: (617) 325-7282