Adhesive capsulitis of shoulder
Synonyms and keywords: Frozen shoulder syndrome; Adhesive capsulitis; Duplay Bursitis, Scapulohumeral periarthritis; Arthofibrosis; Shoulder pain; Shoulder stiffness; Shoulder Capsulitis.

# Overview
Adhesive capsulitis is an inflammatory insult to glenohumeral joint limiting range of motion actively and passively due to pain and stiffness of shoulder joint. The range of motion is debilitated due to inflammation and fibrosis of adhesive bursa due to primary and secondary causes.

# Historical Perspective
- Adhesive capsulitis was first discovered by Simon Emmanuel Duplay, a French surgeon, in 1872 who introduced the term 'scapulohumeral periarthritis' to identify painful shoulder with normal preservation of imaging findings. In 1934 Earnest Codman termed it as Frozen Shoulder' as there was loss of range of motion at shoulder joint. Later in 1945, due to the involvement of inflammation of capsule leading to fibrosis of bursa was elaborated by Julius Neviaser, he named it 'Adhesive capsulitis'.

# Classification
- Adhesive capsulitis may be classified according to etiology into two groups:
- Primary or Idiopathic:
Adhesive capsulitis can occur spontaneously without concurrent shoulder joint abnormality or inciting factors.
- Adhesive capsulitis can occur spontaneously without concurrent shoulder joint abnormality or inciting factors.
- Secondary:
Adhesive capsulitis can present due to preexistent shoulder joint dysfunction for instances glenohumeral joint dislocation with fracture of periarticular region, joint trauma, arthroscopic surgery to shoulder joint, arthroplasty or rotator cuff injury repair. Diabetes mellitus is the most common secondary cause, other than this dysfunctional thyroid gland, adrenal insufficiency, fibromatosis resulting in dupuytren's contracture, cerebrovascular attack, respiratory disease, cardiovascular disease, parkinson's disease, surgery to neck/brain/heart may predispose adhesive capsulitis. 
- Adhesive capsulitis can present due to preexistent shoulder joint dysfunction for instances glenohumeral joint dislocation with fracture of periarticular region, joint trauma, arthroscopic surgery to shoulder joint, arthroplasty or rotator cuff injury repair. Diabetes mellitus is the most common secondary cause, other than this dysfunctional thyroid gland, adrenal insufficiency, fibromatosis resulting in dupuytren's contracture, cerebrovascular attack, respiratory disease, cardiovascular disease, parkinson's disease, surgery to neck/brain/heart may predispose adhesive capsulitis. 

# Pathophysiology
- The pathogenesis of adhesive capsulitis is characterized by inflammation and fibrosis which is elaborated several pathways mentioned below.
In the beginning it was thought myofibroblasts are playing role in fibrotic pathway. low levels of metalloproteinases (MMP 1,2, 14) and elevated expression are shown by tissue inhibitor of metalloproteinases (TIMP 1 or 2) for instances resulting in ECM imbalances and fibrosis.
Inflammatory process involving IL-1s (Both alpha/beta), TNF- alpha, Cyclooxygenases(COX-1 or COX-2) leading to accumulation of macrophages, T and B cells, mast cells are recently thought to have role adhesive capsulitis. 
Molecules like ICAM-1, SNP(single- peptide polymorphism of Interleukin-6), metalloproteinases-3, IGF-2, Beta catenin are involved in genetic association with adhesive capsulitis.  
In recent studies the intolerable pain of adhesive capsulitis is explained by the involvement of nerve invasion by nerve growth factor receptor p75. VEGF, PGP9.5(Protein gene product 9.5), MAPK(mitogen-activated protein kinases)/ENK pathway and MAPK/JNK, Beta-1 integrin(CD19), CD34, NF-kB, TGF- beta, GAP43(growth associated protein 43) are elevated in pathogenesis in Adhesive capsulitis. 
- In the beginning it was thought myofibroblasts are playing role in fibrotic pathway. low levels of metalloproteinases (MMP 1,2, 14) and elevated expression are shown by tissue inhibitor of metalloproteinases (TIMP 1 or 2) for instances resulting in ECM imbalances and fibrosis.
- Inflammatory process involving IL-1s (Both alpha/beta), TNF- alpha, Cyclooxygenases(COX-1 or COX-2) leading to accumulation of macrophages, T and B cells, mast cells are recently thought to have role adhesive capsulitis. 
- Molecules like ICAM-1, SNP(single- peptide polymorphism of Interleukin-6), metalloproteinases-3, IGF-2, Beta catenin are involved in genetic association with adhesive capsulitis.  
- In recent studies the intolerable pain of adhesive capsulitis is explained by the involvement of nerve invasion by nerve growth factor receptor p75. VEGF, PGP9.5(Protein gene product 9.5), MAPK(mitogen-activated protein kinases)/ENK pathway and MAPK/JNK, Beta-1 integrin(CD19), CD34, NF-kB, TGF- beta, GAP43(growth associated protein 43) are elevated in pathogenesis in Adhesive capsulitis. 
- On gross pathology, inflammation, congestion, fibrosis of capsule are characteristic findings of adhesive capsulitis.
- On microscopic histopathological analysis, cellular infiltration with accumulation of macrophages, T and B cells, mast cells  are characteristic findings of adhesive capsulitis.

# Causes
Adhesive Capsulitis may be caused by primarily or Secondarily. Diabetes Mellitus is most common cause of adhesive capsulitis among the secondary cause. The etiologies are:
- Primary or Idiopathic:
Adhesive capsulitis can occur spontaneously without concurrent shoulder joint abnormality or inciting factors
Secondary:
Adhesive capsulitis can present due to preexistent shoulder joint dysfunction for instances glenohumeral joint dislocation with fracture of periarticular region, joint trauma, arthroscopic surgery to shoulder joint, arthroplasty or rotator cuff injury repair.  Systemic illnesses are associated in causing secondary adhesive capsulitis, plays greater role than preexisting joint dysfunction. Diabetes mellitus is the most common secondary cause, other than this dysfunctional thyroid gland, adrenal insufficiency, fibromatosis resulting in dupuytren's contracture, cerebrovascular attack, respiratory disease, cardiovascular disease, parkinson's disease, surgery to neck/brain/heart may predispose adhesive capsulitis. 
- Primary or Idiopathic:
Adhesive capsulitis can occur spontaneously without concurrent shoulder joint abnormality or inciting factors
- Adhesive capsulitis can occur spontaneously without concurrent shoulder joint abnormality or inciting factors
- Secondary:
Adhesive capsulitis can present due to preexistent shoulder joint dysfunction for instances glenohumeral joint dislocation with fracture of periarticular region, joint trauma, arthroscopic surgery to shoulder joint, arthroplasty or rotator cuff injury repair.  Systemic illnesses are associated in causing secondary adhesive capsulitis, plays greater role than preexisting joint dysfunction. Diabetes mellitus is the most common secondary cause, other than this dysfunctional thyroid gland, adrenal insufficiency, fibromatosis resulting in dupuytren's contracture, cerebrovascular attack, respiratory disease, cardiovascular disease, parkinson's disease, surgery to neck/brain/heart may predispose adhesive capsulitis. 
- Adhesive capsulitis can present due to preexistent shoulder joint dysfunction for instances glenohumeral joint dislocation with fracture of periarticular region, joint trauma, arthroscopic surgery to shoulder joint, arthroplasty or rotator cuff injury repair.  Systemic illnesses are associated in causing secondary adhesive capsulitis, plays greater role than preexisting joint dysfunction. Diabetes mellitus is the most common secondary cause, other than this dysfunctional thyroid gland, adrenal insufficiency, fibromatosis resulting in dupuytren's contracture, cerebrovascular attack, respiratory disease, cardiovascular disease, parkinson's disease, surgery to neck/brain/heart may predispose adhesive capsulitis. 

# Differentiating Adhesive capsulitis from other Diseases
For further information about the differential diagnosis, click here.

# Epidemiology and Demographics
- The prevalence of adhesive capsulitis is approximately 2 to 5.3 % in individuals worldwide.
- The incidence of adhesive capsulitis was estimated to be 3 to 5% with 20% cases related with diabetes mellitus.

## Age
- Adhesive capsulitis is more commonly observed among patients aged 40 to 59 years with an average age of 55 years old.

## Gender
- Female are more commonly affected with adhesive capsulitis than male comprising of 70% of total cases.

## Race
- People from African American and Hispanic or Latino race are more likely to have association with Adhesive capsulitis.

# Risk Factors
- Common risk factors in the development of adhesive capsulitis are mentioned below:
Gender: female
Age: 40-59 years
Diabetes Mellitus
Preexistent shoulder joint dysfunction
History of trauma
Immobilization
HLA-B27
Dysfunctional thyroid gland
Adrenal insufficiency
Fibromatosis resulting in dupuytren's contracture
Cerebrovascular attack, respiratory disease, cardiovascular disease
Parkinson's disease
surgery to neck/brain/heart
- Gender: female
- Age: 40-59 years
- Diabetes Mellitus
- Preexistent shoulder joint dysfunction
- History of trauma
- Immobilization
- HLA-B27
- Dysfunctional thyroid gland
- Adrenal insufficiency
- Fibromatosis resulting in dupuytren's contracture
- Cerebrovascular attack, respiratory disease, cardiovascular disease
- Parkinson's disease
- surgery to neck/brain/heart

# Natural History, Complications and Prognosis
- Adhesive capsulitis has clinical features occurring in three distinctive phases. Phases are elaborated below:
Stage 1 or Inflammatory phase or Painful phase: Acute onset of pain with minimal limitation of joint in first three months of frozen shoulder.
Stage 2 or Synovial proliferation phase or Freezing phase: from three to nine months there may be pain with severe intensity with decreased range of active and passive motion.
Stage 3 or Maturation phase with collagenous tissue deposition or Frozen or transitional phase: Marked stiffness with decreased natural swinging of upper extremity in next ninth to fourteenth month of diagnosis.
Stage 4 or Chronic phase or Thawing phase: Frozen shoulder may resolve spontaneously, thus R j Neviaser and T J Neviaser called it thawing phase, but in recent studies it was shown that it may persist as chronic phase.
- Stage 1 or Inflammatory phase or Painful phase: Acute onset of pain with minimal limitation of joint in first three months of frozen shoulder.
- Stage 2 or Synovial proliferation phase or Freezing phase: from three to nine months there may be pain with severe intensity with decreased range of active and passive motion.
- Stage 3 or Maturation phase with collagenous tissue deposition or Frozen or transitional phase: Marked stiffness with decreased natural swinging of upper extremity in next ninth to fourteenth month of diagnosis.
- Stage 4 or Chronic phase or Thawing phase: Frozen shoulder may resolve spontaneously, thus R j Neviaser and T J Neviaser called it thawing phase, but in recent studies it was shown that it may persist as chronic phase.
- If left untreated, Adhesive capsulitis may progress to develop in contralateral shoulder.
- Common complications of adhesive capsulitis include pain and stiffness for long duration, Bicep tendon rupture, Humeral bone fracture.
- Prognosis is generally good and it may resolved within one to three years spontaneously or if treatment is given early with capsulotomy.

# Diagnosis

## Diagnostic Criteria
- The diagnosis of adhesive capsulitis is a diagnosis of exclusion and is made when the following diagnostic criteria are met after evaluating four components according to the Orthopedic department of the APTA's recent guideline: :
- Evaluation or Intervention Component 1 : Screening for other medical conditions.
- Evaluation or Intervention Component 2 : Differentiating the diagnosis with sign/symptoms and evaluating sign and symptoms accordingly.
- Evaluation or Intervention Component 3 : Identify the level of irascibility.
- Evaluation or Intervention Component 4 : Treatment and other required interventions in an appropriate manner.

## Symptoms
- Symptoms of adhesive capsulitis may include the following:
- Diffuse Pain and stiffness of shoulder
- Loss of range of motion actively and passively with limited overhead activity
- Loss of natural swing of arm
- Weakness of affected upper extremity
- Adhesive capsulitis has clinical features occurring in three distinctive phases. Phases are elaborated below:
Stage 1 or Inflammatory phase or Painful phase: Acute onset of pain with minimal limitation of joint in first three months of frozen shoulder.
Stage 2 or Synovial proliferation phase or Freezing phase: from three to nine months there may be pain with severe intensity with decreased range of active and passive motion.
Stage 3 or Maturation phase with collagenous tissue deposition or Frozen or transitional phase: Marked stiffness with decreased natural swinging of upper extremity in next ninth to fourteenth month of diagnosis.
Stage 4 or Chronic phase or Thawing phase: Frozen shoulder may resolve spontaneously, thus R j Neviaser and T J Neviaser called it thawing phase, but in recent studies it was shown that it may persist as chronic phase.
- Stage 1 or Inflammatory phase or Painful phase: Acute onset of pain with minimal limitation of joint in first three months of frozen shoulder.
- Stage 2 or Synovial proliferation phase or Freezing phase: from three to nine months there may be pain with severe intensity with decreased range of active and passive motion.
- Stage 3 or Maturation phase with collagenous tissue deposition or Frozen or transitional phase: Marked stiffness with decreased natural swinging of upper extremity in next ninth to fourteenth month of diagnosis.
- Stage 4 or Chronic phase or Thawing phase: Frozen shoulder may resolve spontaneously, thus R j Neviaser and T J Neviaser called it thawing phase, but in recent studies it was shown that it may persist as chronic phase.

## Physical Examination
- Physician should examine patient by measuring The ASES/The DASH/The SPADI/The Constant score. Physical examination may be remarkable for following signs:
- Mild atrophy of deltoid muscle and supraspinatous muscle with adducted, internally rotated arm  on inspection.
- Poorly localized diffuse tenderness at shoulder joint on palpation.
- Loss of range of motion actively and passively at shoulder joint.
- Complete loss of external rotation.

## Laboratory Findings
- There are no specific laboratory findings associated with adhesive capsulitis as diagnosis is clinical in additional confirmatory imaging findings.

## Electrocardiogram
There are no ECG findings associated with adhesive capsulitis.

## X-ray
An x-ray might be helpful in aiding to diagnose chronic case of Adhesive capsulitis and to rule out other causes of stiff shoulder. Findings on an x-ray suggestive of chronic adhesive capsulitis include disuse osteopenia .

## Echocardiography or Ultrasound
Musculoskeletal ultrasound  may be helpful in the diagnosis of adhesive capsulitis. Findings on an MSK ultrasound diagnostic of adhesive capsulitis include thick coracohumeral ligament, fluid effusion surrounding tendon from long head of biceps.

## CT scan
Coronal oblique CT arthrography scan may be helpful in the diagnosis of adhesive capsulitis. Findings on CT scan suggestive of adhesive capsulitis include thick synovial capsule, resorption of subchondral humeral head, thin recess in axilla.

## MRI
Shoulder MRI and MRA may be helpful in the diagnosis of adhesive capsulitis. Findings on MRI and MRA diagnostic of adhesive capsulitis include decreased rotator interval(RI), enhancement of rotator interval, dysfunctional tissue, thickening of capsules and coracohumeral ligament, axillary recess volume depletion, axillary recess width reduction, T2 MRI showing enhancement of glenohumeral ligament inferiorly.

## Other Imaging Findings
Bone scan with technetium-99m contrast may be helpful in the diagnosis of adhesive capsulitis. Findings on an Bone scan with technetium-99m contrast suggestive of/diagnostic of adhesive capsulitis include 2% uptake in affected part.

## Other Diagnostic Studies
- There are no other diagnostic studies suggestive of adhesive capsulitis.

# Treatment

## Medical Therapy
- The mainstay of therapy for adhesive capsulitis is supportive treatment with NSAIDs and other analgesics.
- Stage 2 treatment are given with NSAIDs, physical therapy, intra-articular injection with steroid.

## Surgery
- Stage 3 treatment are given with exercise with aggressive stretching, local anesthesia manipulation, capsulotomy in surgical release.

## Prevention
- There are no primary preventive measures available for adhesive capsulitis.
- Secondary prevention can be taken as following:
Early treatment and maintenance of chronic illness like diabetes mellitus, SLE, RA.
Daily exposure of exercise with shoulder, neck, back muscle, tendon stretching.
Avoid postures those are detrimental to health, using chair and table of accurate height and distance.
Development of habit of taking nutritious food with accurate amount of vitamins and minerals.
Early practice of ROM exercise postoperatively.
- Early treatment and maintenance of chronic illness like diabetes mellitus, SLE, RA.
- Daily exposure of exercise with shoulder, neck, back muscle, tendon stretching.
- Avoid postures those are detrimental to health, using chair and table of accurate height and distance.
- Development of habit of taking nutritious food with accurate amount of vitamins and minerals.
- Early practice of ROM exercise postoperatively.

# Related Chapters
- Calcific Tendonitis