Adhesive Capsulitis of the Shoulder

Abstract

Adhesive capsulitis is characterized by limited range of motion (ROM) due to adhesions within the glenohumeral joint capsule. The pathophysiology is suspected to involve an inflammatory reaction progressing to fibrotic contracture. Active fibroblastic proliferation can be found on histologic analysis, with some transformation to myofibroblasts, ultimately creating collagen in the form of a thick band. Clinically, adhesive capsulitis is classified into phases: freezing, frozen, and thawing. Risk factors include diabetes, hyperthyroidism, prior fractures, shoulder and cervical spine surgery, and radiation therapy. The condition affects 2% to 5% of individuals, with higher rates in women. While plain radiographs are often unremarkable, magnetic resonance imaging may reveal a thickened capsule, synovial hypertrophy, and joint capsule edema. Nonsurgical treatment focuses on pain relief and restoring ROM and includes physical therapy (PT), oral anti-inflammatory medications, corticosteroid injections, extracorporeal shock wave therapy, and ultrasonography-guided hydrodistention. Early corticosteroid injections are associated with shortened symptom duration and improved functional scores. Both a rotator interval approach, compared with a posterior approach, and lower dosages (10 mg vs 40 mg) of corticosteroid may lead to better pain relief and functional improvement. Ultrasound-guided hydrodilatation with hyaluronic acid combined with PT has also shown superior outcomes compared with PT alone. For patients with diabetes, extracorporeal shock wave therapy avoids potential metabolic complications from steroids. Adhesive capsulitis is self-limiting, with most patients achieving symptom resolution without surgery. Surgical intervention, typically considered after 9 to 12 months of failed nonsurgical management, includes arthroscopic capsular release, manipulation under anesthesia (MUA), or both. Both approaches are efficacious, with improved pain, ROM, and functional scores. Although MUA may be more cost-effective, arthroscopy allows direct visualization and treatment of pathology while reducing the risk of complications from MUA, such as fracture, dislocation, or nerve injury. Postoperative protocols emphasize early PT supplemented by multimodal pain management to maintain and improve ROM.