Adhesive Capsulitis: Diagnosis and Management

 

Am Fam Physician. 2019 Mar 1;99(5):297-300.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/adhesive-capsulitis/.

Author disclosure: No relevant financial affiliations.

Adhesive capsulitis, also known as “frozen shoulder,” is a common shoulder condition characterized by pain and decreased range of motion, especially in external rotation. Adhesive capsulitis is predominantly an idiopathic condition and has an increased prevalence in patients with diabetes mellitus and hypothyroidism. Although imaging is not necessary to make the diagnosis, a finding of coracohumeral ligament thickening on noncontrast magnetic resonance imaging yields high specificity for adhesive capsulitis. Traditionally, it was thought that adhesive capsulitis progressed through a painful phase to a recovery phase, lasting one to two years with full resolution of symptoms without treatment. Recent evidence of persistent functional limitations if left untreated has challenged this theory. The most effective treatment for adhesive capsulitis is uncertain. Nonsurgical treatments include nonsteroidal anti-inflammatory drugs, short-term oral corticosteroids, intra-articular corticosteroid injections, physiotherapy, acupuncture, and hydrodilatation. Physiotherapy and corticosteroid injections combined may provide greater improvement than physiotherapy alone. Surgical treatment options for patients who have minimal improvement after six to 12 weeks of nonsurgical treatment include manipulation under anesthesia and arthroscopic capsule release.

Adhesive capsulitis, also known as “frozen shoulder,” is a common condition of the shoulder defined as a pathologic process in which contracture of the glenohumeral capsule is a hallmark. Clinically, it presents as pain, stiffness, and dysfunction of the affected shoulder.1 Adhesive capsulitis is often self-limited; however, it can persist for years with some patients never regaining full function of their shoulder.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Consider testing persons with adhesive capsulitis for diabetes mellitus or hypothyroidism.

C

3, 4

The combination of physiotherapy and corticosteroid injection may provide greater symptom improvement than physiotherapy alone.

B

13

The combination of hydrodilatation and corticosteroid injection may expedite recovery of pain free range of motion compared with corticosteroid injection alone.

B

17


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Consider testing persons with adhesive capsulitis for diabetes mellitus or hypothyroidism.

C

3, 4

The combination of physiotherapy and corticosteroid injection may provide greater symptom improvement than physiotherapy alone.

B

13

The combination of hydrodilatation and corticosteroid injection may expedite recovery of pain free range of motion compared with corticosteroid injection alone.

B

17


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Epidemiology and Natural History

The prevalence of adhesive capsulitis is estimated at 2% to 5% of the general population. Most patients diagnosed with adhesive capsulitis are women between 40 and 60 years of age.2

Evidence supports an association of adhesive capsulitis with diabetes mellitus and hypothyroidism. A 2016 meta-analysis found that patients with diabetes were five times more likely than the control group to have adhesive capsulitis. The same meta-analysis estimated the prevalence of diabetes in patients with adhesive capsulitis to be 30% (95% confidence interval [CI], 24% to 37%).3 A 2017 case-control study reported the prevalence of a hypothyroidism diagnosis to be significantly higher in the adhesive capsulitis group compared with the control group (27.2% vs. 10.7%; P = .001).4

Traditionally, the natural history of frozen shoulder has been described as a progression through three phases: painful, stiffness, and recovery. Full resolution of symptoms without treatment has been the expected outcome for most patients over one to two years. However, recent clinical evidence of persistent functional limitation, lasting for years, has challenged this theory. A 2017 systematic review of seven studies found low-quality evidence that no treatment yielded some, but not complete improvement in range of motion after one to four years of follow-up. Moderate-

The Author

JASON RAMIREZ, MD, is an assistant professor in the Department of Family and Community Medicine at the University of Maryland School of Medicine in Baltimore.

Address correspondence to Jason Ramirez, MD, University of Maryland School of Medicine, 29 South Paca St., Baltimore, MD 21201 (e-mail: jramirez@som.umaryland.edu). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

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3. Zreik NH, Malik RA, Charalambous CP. Adhesive capsulitis of the shoulder and diabetes: a meta-analysis of prevalence. Muscles Ligaments Tendons J. 2016;6(1):26–34.

4. Schiefer M, Teixeira FS, Fontenelle C, et al. Prevalence of hypothyroidism in patients with frozen shoulder. J Shoulder Elbow Surg. 2017;26(1):49–55.

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11. Jason JI, Sundaram GS, Subramani VM. Physiotherapy interventions for adhesive capsulitis of shoulder: a systematic review. Int J Physiother Res. 2015;3(6):1318–1325.

12. Blanchard V, Barr S, Cerisola FL. The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review. Physiotherapy. 2010;96(2):95–107.

13. Carette S, Moffet H, Tardif J, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum. 2003;48(3):829–838.

14. Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder pain. Cochrane Database Syst Rev. 2005;(2):CD005319.

15. Schröder S, Meyer-Hamme G, Friedmann T, et al. Immediate pain relief in adhesive capsulitis by acupuncture: a randomized controlled double-blinded study. Pain Med. 2017;18(11):2235–2247.

16. Buchbinder R, Green S, Forbes A, Hall S, Lawler G. Arthrographic joint distention with saline and steroid improves function and reduces pain in patients with painful stiff shoulder: results of a randomized, double blind, placebo controlled trial. Ann Rheum Dis. 2004;63(3):302–309.

17. Catapano M, Mittal N, Adamich J, Kumbhare D, Sangha H. Hydrodilatation with corticosteroid for the treatment of adhesive capsulitis: a systematic review. PM R. 2018;10(6):623–635.

18. Ryans I, Montgomery A, Galway R, Kernohan WG, McKane R. A randomized controlled trial of intra-articular triamcinolone and/or physiotherapy in shoulder capsulitis. [Oxford]. Rheumatology (Oxford). 2005;44(4):529–535.

19. Siegel LB, Cohen NJ, Gall EP. Adhesive capsulitis: a sticky issue. Am Fam Physician. 1999;59(7):1843–1852.

 

 

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