Adhesive Capsulitis
Bryce Bederka, MD
Sports Medicine Conference
January 19, 2007
Case #1
n
MD 50 y/o woman
n
4-5 month history of increasing discomfort in the Right shoulder,
acutely worse over past 2-3 weeks, necessitating ER visit
n
Constant pain, increases with use, unable to sleep
n
No history of acute or remote trauma
n
Seen another orthopod who performed subacromial injection without
relief
Case #1
n
Medical history of acid reflux, on Cimetidine
q
Denies other significant, only taking T3 for pain
n
ROM at presentation
n
Elev 70
n
Abd 50
n
ER 0
n
IR ‘limited’
n
Given Vicodin Rx, refused NSAIDs, started on PT program for ROM
Case #1
n
At 6 weeks, 3 mos, 5 mos, pain significantly improved
q
ROM
n
Flex 100
n
Abd 70
n
ER 0/70 20/0
n
IR 0/70 buttock/0
Case 1
Case #2
n
CG, 50 y/o woman
n
Had Right shoulder arthroscopy 4/04 with SA decompression, distal
claviculectomy, rotator cuff repair
q
ROM under anesthesia
n
Elev 160
n
Abd 130
n
ER 0/90 60/60
n
IR 0/90 60/60
Case #2
n
3 months post-op, limited ROM
n
Elev 90
n
Abd 60
n
ER 10-15
n
IR to buttock
n
Subacromial injection improved pain temporarily, but no change in
ROM
n
No improvement with continued therapy, Celebrex, at 5mos, 6mos,
8mos, 10mos
Adhesive Capsulitis
n
Primary
q
Idiopathic
n
Secondary
q
Post-traumatic
q
Post-surgical
q
Post-immobilization
Etiology
n
Exact cause is unknown
q
Autoimmune
q
Inflammatory
q
Endocrine
n
Often no known trauma, or unusual
response based on condition
n
More common in:
q
DM
q
Neurologic diseases
q
HIV – antiretroviral therapy
q
Cancer – breast
q
Thyroid disorders
Epidemiology
n
Will affect 1 in 50 adults
n
Most common from 40-60 years of age
n
70% women
n
Usually non-dominant shoulder
n
1 in 5 will develop symptoms in the contralateral shoulder
Course
n
Phase 1 – Freezing or Painful
q
Painful with any motion
q
Motion deteriorates
q
2-8 months
n
Phase 2 – Frozen or Stiff
q
Pain diminishes, at limits of
motion
q
Motion loss persistent
q
4-12 months
n
Phase 3 – Thawing or Recovery
q
Pain diminishes
q
Motion improves
q
5-24 months
Natural History
n
Primary adhesive capsulitis has a self-limited course
q
Spontaneous resolution can be expected over 1-3 years
q
Some limitations of motion will be persistent in up to 60% of
patients
n
Secondary adhesive capsulitis may be more difficult to treat with
therapy
Anatomy
n
Shoulder joint is an inherently loose articulation
n
Stability primarily maintained by the rotator cuff musculature
q
Compresses G-H joint
n
Capsule and glenohumeral ligaments are normally lax through most
arcs of motion
q
Act at extremes of motion to constrain against excessive movement
Pathoanatomy
n
Capsule
q
Involved with primary adhesive
capsulitis
n
Scarring of specific structures
q
Following stabilization procedures
n
Tissue planes
q
Involved post-fracture or
immobilization
Assessment
n
History
q
Trauma / inciting event
q
Medical conditions
q
Duration of symptoms
n
Physical
q
Active and passive motion
q
Strength
n
Radiographs
q
Arthrography
q
MRI and CT
Patterns of Motion Loss
n
External rotation of adducted shoulder
q
Anterosuperior capsular contracture and rotator interval
n
External rotation of abducted shoulder
q
Anteroinferior capsule
n
Internal rotation, cross-body adduction
q
Posterior capsule
Treatment Options
n
Observation
n
Medication
q
NSAID
q
Steroid
n
Injection
q
Intra-articular
q
Subacromial
q
Distention arthrography
n
Therapy
n
Manipulation under anesthesia
n
Arthroscopic release
q
Capsule
q
Subdeltoid
n
Open release
Observation
n
Gradual resolution of pain over several months
n
Gradual improvement of motion
n
May not achieve full return of motion
n
May take 1-3 years for resolution of symptoms
Medication
n
NSAIDs often prescribed, but no
studies to validate their efficacy
n
Buchbinder, Ann Rheum Dis, 2004
q
Randomized, placebo trial of
prednisone
q
3 week course of 30mg prednisone
daily
q
Improvements in pain, disability
(DASH), SF-36 at 3 weeks
q
Not maintained at 6 weeks or
longer
n
Cochrane Database, 2006
q
Oral steroids effective up to 6
weeks, but no sustained benefit
Injection
n
Arslan, Rheumatolog Int, 2001
q
20 patients
q
Injection of 40mg
methylprednisolone (no PT) vs PT with NSAID
q
Both groups improved similarly
over 12 weeks
n
Ryans, Rheumatology, 2005
q
80 patients
q
3 groups
n
20mg triamcinolone and PT
n
20mg triamcinolone alone
n
PT and placebo injection
q
6 weeks, triamcinolone groups had
less pain and disability, PT groups had better motion
q
16 weeks, all groups improved
equally
Injection
n
Carette, Arthritis Rheum, 2003
q
93 patients
q
Randomized to 4 groups
n
Injection with 40mg triamcinolone
vs placebo
n
Supervised PT vs no PT (all had
home program)
q
Steroid injections provided
improvement at 6 weeks
q
Therapy provided greater earlier
gains in motion
q
All groups equal at 12 months
n
Cochrane Database, 2003
q
Short-term gains, but no long-term
benefit
q
Need larger studies with sound
methodology
Distention arthrography
n
LaRoche, Rev Rheum, 1998
q
40 patients
q
Distention arthrography with
corticosteroids, followed by aggressive PT
q
Significant gains at 5 weeks,
maintained at 1 month
q
No controls, short f/u
n
Poitte, Am J Phys Med Rehabil,
2004
q
15 patients
q
Serial distention arthrograms with
steroid at 3 week intervals, x3
q
Improvements after 1st
and 2nd injections, not after 3rd
q
No control group, short f/u
Physical Therapy
n
Griggs, JBJS-A, 2000
q
71 patients with Stage 2 disease
q
Taught stretching-exercise program
q
Assessed on pain, ROM, function, DASH, SF-36
q
12+ months f/u
q
64 satisfied with results, 7 unsatisfied including 5 who had
surgery
q
Most had residual limitations of motion, but did not affect
function
q
No non-intervention group
Physical Therapy
n
Pajareya, J Med Assoc Thai, 2004
q
121 patients
q
Randomised to NSAID alone, or with
PT, for 3 weeks
q
PT and NSAID sig better at 3 weeks
q
No difference at 12 weeks
n
Vermeulen, Phys Ther, 2006
q
Comparison of high-grade vs
low-grade mobilization techniques
q
Both groups demonstrated
improvements over 12 months
q
HGMT had significant improvement
in motion parameters at 12 months as compared to LGMT
Manipulation Under Ansethesia
n
Kivimaki, Arch Phys Med Rehabil,
2001
q
24 patients
q
Randomized to manipulation alone
or manipulation with intra-articular corticosteroid
q
Both groups improved for pain and
ROM at post-op visit
q
No difference between groups
n
Loew, JSES, 2005
q
Arthroscopy following 30
manipulations
q
All demonstrated some degree of
synovitis
q
All had capsular rupture
n
18 had no additional lesions
n
4 SLAP
n
3 partial subscapularis tears
n
4 anterior labral detachments
n
2 MGHL tears
Arthroscopic Release
n
Jerosch, KSSTA, 2001
q
28 patients who had failed 6
months therapy
q
At 6 weeks post-op, all ROM and
Constant scores were improved significantly
q
No control group, short f/u
n
Holloway, JBJS-A, 2001
q
50 patients with idiopathic,
post-surgical, or post-fracture adhesive capsulitis
q
At mean 20 months, all patients
had improvement in ROM, pain, and function scores
q
Post-surgical adhesive capsulitis
patients had slightly less improvement
Arthroscopic Release
n
Berghs, JSES, 2004
q
25 patients
q
At 14 months post-op, all had improvement in pain, passive ROM,
Constant score and SF-36
n
Diwan, Arthroscopy, 2005
q
40 patients, 2 year f/u
q
Standard anterior release vs extended release
q
The extended release with supervised post-op PT program produced
greater and lasting gains
Open Release
n
Omari, JSES, 2001
q
25 patients treated with open surgical release
q
20 months f/u
q
Results: 20 G/E, 3 Fair, 2 Poor
n
1 IDDM
n
1 bilateral Dupuytrens
q
Results more favorable in non-diabetics
The Future?
n
Clinical trial being undertaken in NY to evaluate use of
collagenase injected intra-articularly
What do we know?
n
Most interventions produce short-term improvements in symptoms
n
Some interventions produce short-term improvements in function
n
All patients have long-term improvement in pain and function
regardless of intervention
Home Exercises
n
Simple exercise program
n
No special equipment
n
Can do anywhere
Posterior Capsular Stretches
Shoulder Manipulation
n
Described technique of
manipulation without rotation based on Codman’s paradox
n
76 sequential manipulations with
improvement in ROM and without fracture or other complication
Arthroscopic Release
n
Release is performed at the
glenoid side of the capsule
q
Minimizes risk to nerve
n
Technique requires changing
portals to complete release
n
Can do selective release and check
motion
Open Release
n
Anterior deltopectoral approach
allows debridement of subdeltoid space
Open Release
n
Subscapularis contracture can be
treated by intrasubstance Z-lengthening of tendon and capsule
Open Release
n
Subscapularis mobilization when
muscle is adherent to capsule
Principles of Treatment
n
In Phase 1, treatment goal is palliative
q
Do not operate
q
Physical Therapy with aggressive stretching may be counter
productive
n
Secondary Adhesive Capsulitis is less likely to respond to
conservative measures
q
Low threshold for return to OR
n
Physical exam can help determine extent of release needed
Principles of Treatment
n
Arthroscopic release can address entire capsule, rotator interval,
subdeltoid space
n
Release close to glenoid to minimize risk to cuff tendons and
axillary nerve
n
Positioning in beach chair allows easy conversion to open
procedure
Case #1
n
10/04, taken to OR for MUA,
Arthroscopic 360º capsular release
q
ROM EUA
n
Flex 90
n
Abd 60
n
ER 0/90 10/30
n
IR 0/90 40/0
q
ROM post-op
n
Flex 170
n
Abd 120
n
ER 0/90 90/100
n
IR 0/90 NR/60
q
ROM 4 months, Occasional
functional and night pain
n
Flex 160
n
Abd 160
n
ER 0/90 40/50
n
IR L2
Case #2
n
2/05, taken to OR for MUA,
Arthroscopic 360º capsular release
q
ROM EUA
n
Elev 110
n
Abd 90
n
ER 0/90 30/30
n
IR 0/90 30/20
Case #2
q
ROM post-op
n
Elev 150
n
Abd 120
n
ER 0/90 80/90
n
IR 0/90 NR/70
q
ROM 4 months, Minimal functional
pain
n
Elev 145
n
Abd 110
n
ER 0/90 35/NR
n
IR Buttock