II. Definition

  1. Shoulder Pain and limited range of motion stemming from disuse

III. Epidemiology

  1. Age over 40 years
  2. Women more commonly affected

IV. Risk Factors

  1. Chronic Shoulder Pain (results in disuse)
    1. Bicipital Tenosynovitis
    2. Rotator Cuff Tendinitis
    3. Shoulder Band Syndrome (Reflex Sympathetic Dystrophy)
  2. Comorbid conditions that predispose to Adhesive Capsulitis
    1. Diabetes Mellitus
    2. Thyroid Disease

V. Symptoms

  1. Gradual onset of decreased Shoulder stiffness
  2. Pain onset after significant Shoulder Range of Motion lost
  3. Pain well localized to rotator cuff
  4. Pain radiation into deltoid and anterior arm
  5. Pain interferes with sleep (unable to lie on Shoulder)

VI. Signs

  1. Inspection
    1. Patient holds arm protectively at side
    2. Deltoid and Supraspinatus atrophy
  2. Palpation
    1. Generalized pain at rotator cuff and biceps tendon
  3. Limited range of motion
    1. Loss of both active and passive Shoulder Range of Motion (pathognomonic)
    2. Loss of motion in all planes
    3. Normal range of motion excludes Adhesive Capsulitis as a diagnosis
  4. Associated Findings: Reflex Sympathetic Dystrophy
    1. Hand Edema, coolness, and discoloration

VII. Differential Diagnosis

VIII. Imaging: Shoulder XRay

  1. Typically normal in Adhesive Capsulitis
  2. Evaluate differential diagnosis
    1. Posterior Shoulder Dislocation
    2. Glenohumeral Osteoarthritis

IX. Management

  1. Conservative measures to relieve pain
    1. Relative rest
    2. Moist heat
    3. Sedation to assist sleep at night
    4. Analgesics
      1. NSAIDs
      2. Often requires Opioid Analgesics
  2. Physical Therapy (Start as soon as possible)
    1. See Shoulder Range of Motion Exercises
    2. Avoid aggressive mobilization as it may prolong the course
    3. Initially, home Exercises are performed hourly
  3. Oral Corticosteroid
    1. NSAIDS and Subacromial Corticosteroid Injection are preferred
      1. Oral Corticosteroids risk significant adverse effects
    2. Dosing
      1. Prednisone 20 mg orally daily for 3-4 weeks
    3. Efficacy
      1. Superior to physical therapy or Acetaminophen is improved function and decreased pain in the first 1-2 months
  4. Subacromial Corticosteroid Injection
    1. Indicated at 6 weeks for course refractory to conservative measures and physical therapy
    2. Restart Shoulder Range of Motion Exercises at 1 week after injection
    3. Ryans (2005) Rheumatology 44:529-35 [PubMed]
  5. Aspiration and Lavage (Barbotage)
    1. Performed under Ultrasound guidance
    2. Preanesthesize with 1% Lidocaine via a 27 gauge needle
    3. Large bore needle (16-18 gauge) placed within calcific deposits
      1. Lidocaine 1% mixed 1:1 with Normal Saline with 10 cc syringe (6-8 cc per syringe)
      2. Insert needle within calcific deposit and rotate needle bevel to create seal
      3. Pepper the calcific deposit, injecting the Lidocaine/saline
      4. Apply constant back pressure on plunger
      5. Calcium deposits will be withdrawn into plunger
    4. References
      1. Shapiro (2016) Advanced U/S Guided Injections, GCUS Musculoskeletal Ultrasound, 1/28/2016
      2. Gatt (2014) Arthroscopy 30(9):1166-72 +PMID: 24813322 [PubMed]
  6. Surgical Intervention (rarely needed now)
    1. Indicated for intolerable symptoms at 6-12 weeks refractory to above measures
    2. Procedures
      1. Careful Shoulder manipulation under general anesthesia
        1. Exercise caution in patients with Osteoporosis, Osteopenia or Glenohumeral Instability
        2. Risk of Proximal Humerus Fracture
        3. Glenohumeral Dislocation
        4. Rotator Cuff Tear
      2. Capsular release by Shoulder arthroscopy
      3. Cervical Sympathetic Nerve blocks (used historically for refractory pain control)

X. Prevention

  1. See Shoulder Range of Motion Exercises
  2. Maintain Shoulder Range of Motion at time of injury
    1. Start shoulder Pendulum Exercises and wall walking Exercises early following Shoulder injury
  3. Avoid Shoulder immobilization if at all possible (especially if age >50 years old)
    1. If immobilization required, avoid immobilization >3-7 days

XI. Course

  1. Insidious onset of pain
  2. Chronic, full recovery may take over 6 months
  3. Most regain near full motion of Shoulder within 1-2 years even without intervention

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Adhesive Capsulitis (C0158300)

Concepts Disease or Syndrome (T047)
MSH D002062
English Adhesive Capsulitides, Capsulitides, Adhesive, Capsulitis, Adhesive, Capsulitis;adhesive, adhesives capsulitis, capsulitis adhesive, adhesive capsulitis, Adhesive capsulitis, capsulitis; adhesive, adhesive; capsulitis, Adhesive Capsulitis
Dutch adhesive capsulitis, adhaesiva; capsulitis, capsulitis; adhaesiva, Adhesieve capsulitis, Capsulitis, adhesieve
French Capsulite adhésive, Capsulite rétractile de l'épaule
German adhaesive Kapsulitis, Adhäsive Kapsulitis, Kapsulitis, adhäsive
Portuguese Capsulite adesiva, Capsulite Adesiva
Spanish Capsulitis adhesiva, Capsulitis Adhesiva
Japanese 癒着性関節包炎, ユチャクセイカンセツホウエン
Czech adhesivní capsulitis, adhezivní kapsulitida, Adhezivní kapsulitida
Hungarian Adhesiv capsulitis
Italian Capsulite adesiva
Norwegian Adhesjonskapsulitt, Adhesiv kapsulitt

Ontology: Frozen shoulder (C0311223)

Concepts Disease or Syndrome (T047)
MSH D002062
ICD9 726.0
ICD10 M75.0
SnomedCT 268087008, 202837002, 8753005, 156658000, 156664007, 202847004, 399114005
English Frozen shoulder, Adhesive capsulitis of should, adhesive capsulitis of shoulder, adhesive capsulitis of shoulder (diagnosis), Adhesive capsulit shlder, Frozen Shoulder, frozen shoulder syndrome, frozen shoulders, adhesive capsulitis shoulder, frozen shoulder, shoulder frozen, shoulder adhesive capsulitis, Pericapsulitis, shoulder, Adhesions-capsulitis,shoulder, Adhesive capsulitis shoulder, Frozen shoulder (disorder), Adhesive capsulitis of the shoulder, Adhesive capsulitis of shoulder, Pericapsulitis of shoulder, Adhesive capsulitis of shoulder (disorder), bursitis; Duplay, capsulitis; adhesive, shoulder, frozen; shoulder, adhesive; capsulitis, shoulder, adhesive; tendinitis, shoulder, shoulder; frozen, tendinitis; adhesive, shoulder
Dutch frozen shoulder, adhesive capsulitis van schouder, adhaesiva; capsulitis, schouder, adhesief; tendinitis, schouder, bursitis; Duplay, capsulitis; adhaesiva, schouder, frozen; shoulder, shoulder; frozen, tendinitis; adhesief, schouder, Adhesieve capsulitis van schouder
French Capsulite adhérente de l'épaule, Epaule bloquée, Épaule gelée
German adhaesive Capsulitis der Schulter, steife Schulter, Adhaesive Entzuendung der Schultergelenkkapsel, Schultersteife, Frozen Shoulder, Eingesteifte Schulter
Italian Capsulite adesiva della spalla, Spalla congelata
Portuguese Periartrite escapulumeral, Capsulite adesiva do ombro, Ombro Congelado
Spanish Capsulitis adhesiva de hombro, Hombro congelado, Hombro Congelado, capsulitis adhesiva del hombro (trastorno), capsulitis adhesiva del hombro, capsulitis retráctil, hombro rígido, capsulitis adhesiva de hombro, capsulitis adhesiva de hombro (trastorno), bursitis adherente
Japanese 癒着性肩関節包炎, 凍結肩, トウケツカタ, トウケツケン, ユチャクセイカタカンセツホウエン
Czech Adhezivní kapsulitida ramene, Zmrzlé rameno, syndrom zmrzlého ramene, zmrzlé rameno, frozen shoulder, zamrzlé rameno, syndrom zamrzlého ramene
Korean 어깨의 유착성 피막염
Hungarian Fagyott váll, Váll adhesiv capsulitise
Norwegian Adhesiv kapsulitt i skulder, Frossen skulder, Adhesjonskapsulitt i skulder, Frozen shoulder, Stiv skulder