Clinical Presentation of Adhesive Capsulitis

The shoulder joint is one of the most mobile joints with an extraordinary range of motion (ROM). Adhesive capsulitis is a benign, self-limiting musculoskeletal condition that has a disabling capability. Adhesive capsulitis, commonly known as frozen shoulder causes pain and restriction of ROM of ≥ 25% in at least two directions; mainly shoulder abduction and external rotation. Numerous physical characteristics like thickening of a synovial capsule, capsular contracture, adhesions within subacromial or subdeltoid bursa are important to assess to diagnose adhesive capsulitis. A clinician should be well aware of cardinal signs of the frozen shoulder at different clinical phases of this disabling shoulder condition in order to differentiate it from various other clinically similar shoulder pathologies.

Incidence

Adhesive capsulitis is most common in the diabetic population (20%) while it has an incidence of 3% – 5% in general population. This shoulder condition is one of the most common clinical cases seen in orthopedics or physiotherapy. Typically, frozen shoulder is common among female in their 5^th to 7^th decades of life is usually diagnosed with frozen shoulder.

Adhesive capsulitis classification

1. Primary, which is idiopathic and insidious in onset.
2. Secondary, which is generally the result of trauma or prolonged immobilization due to the various causes.

Clinical phases / presentation

Clinical presentation of adhesive capsulitis is generally reported as 3 distinct overlapping clinical stages. Literature has presented this condition as self-limiting with symptoms resolution as early as 6 months up to 11 years. However, many patients may never fully recover from the symptoms.

• Stage 1

  The first stage of this condition is acute stage, freezing or painful stage. The onset of pain is slow with nagging pain at rest and sharp pain at extremes of motion. Patients may not see the medical condition as they will usually wait thinking that eventually, the pain will subside itself with some self-home based intervention or on its own after some rest. However, symptoms progress, pain worsens with pain at night causing sleep disturbance. There will be a slow progression in the reduction of both active and passive range of motion. So, typically patients end up in the clinic at the late stage of the first phase. This stage typically lasts between 3^rd up to 9^th months and is clinically characterized by an acute synovitis of the glenohumeral joint.

• Stage 2

  In most of the cases, patients will progress to the second stage; Adhesive, frozen, stiffness or transitional phase. During this stage, there will be no worsening of pain but will be a significant progressive restriction of ROM in a capsular pattern. Ther can be excruciating pain only at end range of movements causing limitation of arm movement and thus muscular disuse. The common capsular pattern of the glenohumeral joint is external rotation being most limited followed by shoulder abduction and internal rotation. At a later stage of this phase, there can be a point where there is no pain even at end ROM but both active and passive ROM is significantly reduced. This phase usually starts at 4 months and lasts up to about 12 months.

• Stage 3

  The final or third phase is resolution or thawing stage when ROM begins to improve gradually. This spontaneous and progressive improvement of functional ROM or shoulder mobility can last anywhere from 12-42 months.

Differential diagnosis

Some conditions to consider in differential diagnosis to adhesive capsulitis are osteoarthritis, bursitis, Parsonage- tunnel syndrome, rotator cuff pathologies, posterior dislocation etc.

Outcome measures commonly used

• Shoulder pain and disability index (SPADI)
• Disability of arm, shoulder and hand scale (DASH)
• Penn shoulder scale (PSS)
• Simple shoulder test (SST)
• VAS
• NPRS
• SF-36

References

Anton HA. Frozen shoulder. Can Fam Physician. 1993;39:1772–8

Cleland J, Durall CJ. Physical therapy for adhesive capsulitis: Systematic review. Physiotherapy 2002;88:450-457.

Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ 2005; 331:1453-6.

Jayson M. Frozen shoulder: adhesive capsulitis. Br Med J. 1981;283:1005–6.

Kline CM. Adhesive capsulitis: clues and complexities. JAMA Online 2007;2-9

Murnaghan JP. Adhesive capsulitis of the shoulder: current concepts and treatment. Orthopedics. 1988;11(1):153–8.

Neviaser JS. Adhesive capsulitis and the stiff and painful shoulder. Orthop Clin North Am. 1980;11:327–31.

Walmsley S, Rivett DA, Osmotherly PG. Adhesive capsulitis: Establishing consensus on clinical identifiers for stage 1 using the delphi technique. Phys Ther 2009;89:906-917.