Adhesive Capsulitis Treatment Options

What is Adhesive Capsulitis?

Adhesive capsulitis, or "frozen shoulder syndrome" describes an ongoing and painful limitation of active and passive shoulder and scapular motion. Adhesive capsulitis may be classified as "primary" or "secondary". Patients with "primary" adhesive capsulitis are unable to identify the genesis of their adhesive capsulitis of shoulder condition. "Secondary" capsulitis is more common and follows a period of restricted shoulder motion or immobilization (i.e. rotator cuff pathology, trauma, surgery, etc). One study found that patients who underwent a period of unrelated shoulder immobilization were 5-9 times more likely to experience adhesive capsulitis.

Adhesive capsulitis is thought to affect 2-5% of the population at some point in their lifetime. Concurrent medical issues may increase one's risk for developing adhesive capsulitis. The incidence of adhesive capsulitis of shoulder rises to 10-20% in those with Type 2 diabetes, and 36% in those with Type 1 diabetes. In patients with primary adhesive capsulitis, 38% of men and 24% of women have diabetes. Additionally, diabetics tend to experience protracted recoveries and poorer clinical outcomes in adhesive capsulitis treatment. Patients with thyroid disease are also at increased risk for developing adhesive capsulitis.

Adhesive capsulitis is most common in the 40-65-year old population with a peak incidence between 51 and 55.  Females are affected more frequently. The adhesive capsulitis of shoulder condition shows no preference for handedness, but those who have had a prior episode in the contralateral arm are at greater risk.

What Will Adhesive Capsulitis Look and Feel Like?

Symptoms of adhesive capsulitis include progressive pain, most focal to the side of the arm, with sharp intensification at end range of motion. Night pain and sleep disturbances are common. Functional range of motion deficits limit reaching overhead, behind the back, or to the side. Patients often report difficulty grooming and dressing. Symptoms have generally progressed or plateaued for at least one month prior to presentation.

Adhesive capsulitis of the shoulder may be subdivided into 3 or 4 contiguous stages.

Stage 1 is the "pre-cursor" phase characterized by achiness that becomes sharp at (relatively preserved) end range. Histologically, the shoulder joint is undergoing a diffuse synovial reaction/inflammation.

Stage 2 is recognized as the "painful" or "freezing" stage that demonstrates a gradual progressive loss of shoulder range of motion over the next weeks to months, as the shoulder joint undergoes more aggressive proliferative inflammation processes. The development of new nerve growth during this phase may contribute to a heightened pain response.

Stage 3 is the "frozen" stage of adhesive capsulitis of shoulder, characterized by pain and significant loss of range of motion for the next several months. Histologically, the shoulder undergoes progressive fibrosis, capsular thickening, and adhesions in the subarachnoid bursa, subdeltoid bursa, biceps tendon, and intraarticular subscapularis tendon. This period of prolonged immobilization may lead to long-term detrimental consequences, including atrophy, degeneration, and permanent motion restrictions.

Stage 4 is the "thawing" stage that is associated with progressively decreasing pain and stiffness. Patients may require up to nine months to regain a functional range of motion.

How Do We Manage Adhesive Capsulitis?

No single intervention seems to be significantly more effective than any other in the treatment of adhesive capsulitis of shoulder (which suggests that there are no overly effective options). A collection of studies on the effectiveness of manual therapy for the treatment of adhesive capsulitis shows varied outcomes, with the majority demonstrating improvements in range of motion, pain, and function. At least one study shows similar improvement with “supervised neglect.”

Manual techniques including active and passive stretching, mobilizations of the shoulder and scapular joints, as well as cervical and thoracic spinal manipulations/adjustments are all useful interventions in attempt to restore motion and function of the affected adhesive capsulitis of shoulder. Implementation of these exercises to improve scapular mobility and function are associated with improved outcomes. Heat, ultrasound, and electrical stimulation modalities may provide palliative relief as an adjunct to manual therapy, however, are not expected to progress range of motion. Dry needling has also shown to be effective to improve pain, disability, and range of motion in some cases.

Adhesive capsulitis of shoulder has traditionally been thought of as a self-limiting disorder lasting up to 18 months, with residual motion deficits in at least 10% of patients. In some cases, symptoms may last for years. Patients must clearly understand the natural chronicity of this condition to limit apprehension and adhesive capsulitis treatment frustration.