How does adhesive capsulitis occur

Moving the shoulder less and less increases its stiffness. Reaching for an item on a high shelf becomes difficult, if not impossible. If you have a hormonal imbalance, diabetes, or a weakened immune system, you may be prone to joint inflammation.

A long period of inactivity due to an injury, illness, or surgery also makes you more vulnerable to inflammation and adhesions, which are bands of stiff tissue. In serious cases, scar tissue may form. This severely limits your range of motion. Usually, the condition takes two to nine months to develop. If you feel stiffness and pain in your shoulder, see your doctor.

A physical exam will help to assess your range of motion. Your doctor will observe as you perform specific movements and measure range of motion of the shoulder, such as touching your opposite shoulder with your hand. A few tests may also be necessary. Your doctor might do a magnetic resonance imaging scan MRI to rule out a tear in your rotator cuff or other pathology.

X-rays may also be taken to check for arthritis or other abnormalities. You may need an arthrogram for the X-ray, which involves injecting dye into your shoulder joint so that the doctor can see its structure.

You can leave a frozen shoulder untreated, but the pain and stiffness can remain for up to three years. A combination of the following can speed up your recovery:. Physical therapy is the most common treatment for a frozen shoulder. The goal is to stretch your shoulder joint and regain the lost motion. It can take anywhere from a few weeks to nine months to see progress. A home exercise program of gentle range of motion exercises is important. Immobility may be the result of many factors, including:.

People who have certain diseases appear more likely to develop frozen shoulder. Diseases that might increase risk include:. One of the most common causes of frozen shoulder is the immobility that may result during recovery from a shoulder injury, broken arm or a stroke. If you've had an injury that makes it difficult to move your shoulder, talk to your doctor about exercises you can do to maintain the range of motion in your shoulder joint. Mayo Clinic does not endorse companies or products.

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The unaffected shoulder will accommodate 20 to 30 mL of contrast material, whereas the shoulder with adhesive capsulitis will only be able to hold 5 to 10 mL. Arthrograms may reveal an irregularity of the capsular insertion at the anatomic humeral neck and a decreased axillary fold.

From 10 to 30 percent of patients are found to have a demonstrable rotator cuff tear at arthrography, yet a significant number also have normal findings. Arthrography should be reserved for use in patients whose diagnosis remains uncertain following physical examination and radiography. Arthroscopy may have a limited role in the diagnosis of other diseases that mimic adhesive capsulitis, but it does not aid in the diagnosis of adhesive capsulitis itself and is not used frequently.

MRI may become a useful, noninvasive way to document capsular thickening, but further studies are needed. In most cases, the diagnosis of adhesive capsulitis is clinical; however, if any imaging is necessary, arthrography remains the procedure of choice.

If there are no underlying illnesses, laboratory investigations will be unremarkable. Some systemic diseases are known to be associated with adhesive capsulitis Table 3 and should be considered in patients with restricted shoulder movement.

Trauma, avascular necrosis and osteoarthritis may predispose a patient to secondary adhesive capsulitis. Systemic diseases such as diabetes, hyperthyroidism and rheumatoid arthritis are also associated with secondary adhesive capsulitis and must be considered in a patient with limited range of motion of the shoulder. It is unclear why patients with a history of myocardial infarctions, cerebrovascular accidents and chronic pulmonary diseases, such as tuberculosis and pulmonary cancer, are also predisposed to adhesive capsulitis.

Patients with reflex sympathetic dystrophy related to some of these events may have restricted range of motion of the shoulder that becomes permanent in the later stages of disease. Some patients may also develop reflex sympathetic dystrophy as a result of primary or secondary adhesive capsulitis. Although studies comparing various treatment modalities for adhesive capsulitis reveal that no specific treatment method has any long-term advantage, early and accurate diagnosis is imperative.

The first step is preventing secondary adhesive capsulitis by definitively addressing underlying causes. Avoiding prolonged immobilization in patients who may be predisposed to adhesive capsulitis is crucial. Treatment of a shoulder injury of any etiology requires early range of motion therapy to reduce muscle spasm while maintaining full range of motion.

Heat, cold and other modalities that relax the muscles may help preserve range of motion. Adequate analgesia is necessary for successful treatment in this phase. Vigorous and forceful exercises are contraindicated because of the pain associated with the rupture of adhesions.

Also, the more painful treatment regimens have been found to be associated with a higher level of non-compliance. Constant encouragement is necessary for patients with adhesive capsulitis, since resolution may be slow. Gradually increasing the range of motion of the shoulder will decrease the pain associated with the disease. Muscle relaxants are helpful in the early stages of the disease when spasm is predominant.

Low-dose antidepressant medications e. Intra-articular corticosteroid injections are used in affected patients to relieve pain and permit a more vigorous physical therapy routine. The injection site is located 1 cm distal and 1 cm lateral to the coracoid process 18 Figure 8.

Full external rotation of the humerus with the elbow held in a relaxed position at the patient's side helps open up the space, which is difficult to enter if contracted by adhesive capsulitis. Although intra-articular corticosteroids are frequently used, no long-term benefits from this therapy i.

Some clinicians advocate simultaneous intra-articular and bursal injections for pain relief before beginning physical therapy. Oral corticosteroids are not helpful. Severe adhesive capsulitis diagnosed in the later stages is more difficult to manage. The above treatments, useful on occasion, are not always successful. Surgical intervention should be considered when physical therapy and injections fail no improvement after three months of therapy.

Manipulation under anesthesia to break up the adhesions is reserved for use in the adhesive stage. During this procedure, the joint capsule and sub-scapular muscles are ruptured, and aggressive rehabilitation is employed to restore and maintain range of motion of the shoulder. Patients undergoing manipulation may receive an intra-articular corticosteroid injection after the procedure and begin physical therapy the day of the procedure.

Icing is often helpful. Another option is the administration of an interscalene block before the manipulation; this renders the patient pain free and allows for the immediate start of physical therapy. Risks associated with manipulation under anesthesia include humeral fracture, dislocation and rotator cuff rupture. Contraindications to manipulation include severe osteopenia, a history of fracture or dislocation, or recurrence following adequate manipulation. Some investigators 21 demonstrated that arthroscopic release was helpful in patients with diabetes-associated adhesive capsulitis who were refractory to conservative measures.

Thirteen of the patients studied had no pain, full range of motion and full function after surgical release. Interestingly, a marked discrepancy exists between the patient's subjective awareness of residual range deficit and the measurable objective restrictions. Many patients with range deficits regard their recovery as complete.

This difference in subjective and objective assessment of recovery, plus the variation and confusion in the definitions of adhesive capsulitis, may account for the conflicting reports of prognosis and therapy. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. She is director of undergraduate education in the Department of Medicine. Siegel received her medical degree from the Medical College of Wisconsin, Milwaukee, and completed a residency in internal medicine and a fellowship in rheumatology at Georgetown University Hospital, Washington, D.

He is also on staff at Highland Park Ill. ERIC P. Gall is also professor of immunology and microbiology at the same institution. He received his medical degree from the University of Pennsylvania School of Medicine, Philadelphia, where he also completed a residency in internal medicine and a fellowship in rheumatology. Address correspondence to Lori B. Siegel, M. Reprints are not available from the authors. Neviaser JS. Adhesive capsulitis of the shoulder: a study of the pathologic findings in periarthritis of the shoulder.

J Bone Joint Surg. Johns Hopkins shoulder surgeon Dr. Uma Srikumaran explains how this technology can be used to treat people who are not candidates for normal total shoulder replacement. The two main goals of treatment are to increase motion and to decrease pain.

To increase motion, physical therapy is usually prescribed. The physical therapist moves the patient's arm to stretch the capsule and teaches the patient home exercises that may include use of a wand or overhead pulley. He or she may also use ice, heat, ultrasound or electrical stimulation. The therapist will demonstrate a stretching program that you should do at least once or twice a day.

These exercises include the use of a cane, a home pulley system and an elastic cord to increase motion of the shoulder. To decrease pain, physicians frequently recommend anti-inflammatory medications such as aspirin, ibuprofen Motrin, Advil , Naprosyn or Aleve. Pain pills such as Tylenol or narcotics may be prescribed to decrease the pain after therapy or to help with sleep at night. Occasionally, steroid injections of the joint or the bursa may be indicated. Steroids like prednisone, taken by mouth, may be given to help decrease the inflammation.

Supervised physical therapy usually lasts from one to six weeks, with the frequency of visits ranging from one to three times per week.