Diagnosis and management of adhesive capsulitis

Nevner det meste av medisinske behandlingsmetoder for frozen shoulder. Men kun medisiner eller kirurgi nevnes. Bedring fra 92% til 165% fremad elevasjon stående, og fra 12% til 52% utrotasjon av armen ryggliggende er resultatene av kirurgi. Dette har jeg også fått til ved hjelp av dry needling og behandlingene på Verkstedet.


Adhesive capsulitis is diagnosed by numerous physical characteristics including a thickening of the synovial capsule, adhesions within the subacromial or subdeltoid bursa, adhesions to the biceps tendon, and/or obliteration of the axillary fold secondary to adhesions [19].

Adhesive capsulitis has an incidence of 3–5% in the general population and up to 20% in those with diabetes. This disorder is one of the most common musculoskeletal problems seen in orthopedics [1115]. Although some have described adhesive capsulitis as a self-limiting disorder that resolves in 1–3 years [131620], other studies report ranges of between 20 and 50% of patients with adhesive caspulitis which suffer long-term ROM deficits that may last up to 10 years [2125].

Adhesive capsulitis is commonly associated with other systemic and nonsystemic conditions. By far the most common is the co-morbid condition of diabetes mellitus, with an incidence of 10–36% [142728].

Other co-morbid conditions include hyperthyroidism, hypothyroidism, hypoadrenalism, Parkinson’s disease, cardiac disease, pulmonary disease, stroke, and even surgical procedures that do not affect the shoulder such as cardiac surgery, cardiac catheterization, neurosurgery, and radical neck dissection [2939].

Adhesive capsulitis is classified into two categories: (1) primary, which is insidious and idiopathic, or (2) secondary, which is generally due to trauma or subsequent immobilization [41]. Those with primary adhesive capsulitis generally have a very gradual onset and progression of symptoms, with no known precipitating event that can be identified [42].

Adhesive capsulitis presentation is generally broken into three distinct stages [43]. The first stage that is described is called the freezing or painful stage. Patients may not present during this stage because they think that eventually the pain will resolve if self-treated.

This phase typically lasts between 3 and 9 months and is characterized by an acute synovitis of the glenohumeral joint [44].

Most patients will progress to the second stage, the frozen or transitional stage. During this stage shoulder pain does not necessarily worsen. Because of pain at end ROM, use of the arm may be limited causing muscular disuse. The frozen stage lasts anywhere 4 to 12 months [44].

The third stage begins when ROM begins to improve. This 3rd stage is termed the thawing stage. This stage lasts anywhere from 12 to 42 months and is defined by a gradual return of shoulder mobility.

Pain associated with adhesive capsulitis can cause a limitation or selective immobilization of the painful shoulder. Prolonged immobilization of a joint has been shown to cause several detrimental pathophysiologic findings including: decreased collagen length, fibrofatty infiltration into the capsular recess, ligament atrophy resulting in decreased stress absorption, collagen band bridging across recesses, random collagen production, and altered sarcomere number in muscle tissue [45].

Testing for impingement may be positive with a Hawkin’s or Neer sign; however, the pain is likely from the intrinsic process of impingement or capsular stretch rather than from adhesive capsulitis.

The diagnosis of adhesive capsulitis is often one of exclusion. Early in the disease process adhesive capsulitis may clinically appear similar to other shoulder conditions such as major trauma, rotator cuff tear, rotator cuff contusion, labral tear, bone contusion, subacromial bursitis, cervical or peripheral neuropathy. Additionally, a history of a previous surgical procedure can lead to shoulder stiffness. If a history of these other pathologies are negative and if radiographs do not demonstrate osteoarthritis, then the diagnosis can be given.

Non-operative treatment


Treatment of adhesive capsulitis often involves the use of anti-inflammatories, or corticosteroids. NSAIDs may be used during any phase as an attempt to relieve symptoms. There are no well done studies to indicate that NSAIDs change the natural history of adhesive capsulitis.

Intra-articular corticosteroid injections

Although high-quality randomized studies of corticosteroid injection for treatment of adhesive capsulitis have not been done, there is some evidence to indicate there is a short-term benefit with their use.

Surgical treatment

The treatment of adhesive capsulitis should lead to the operating room only after a concerted effort at conservative management has failed.

Manipulation under anesthesia

Manipulation under anesthesia as a means of treatment has been advocated. This method allows return of ROM in the operating room. Immediate postoperative physical therapy can be initiated with this form of treatment [49]. Manipulation under anesthesia has the disadvantage in that tissues that are stretched while the patient is under anesthesia may cause pain when awake. This can potentially slow recovery. When surgical release is added to this procedure it induces further surgical trauma to the shoulder and may slow rehabilitation.

Arthroscopic release and repair

Arthroscopy is an excellent additional tool for addressing the shoulder with adhesive capsulitis, and has become well accepted in treating this process. The essential lesion is the tightened coracohumeral ligament and rotator interval with the contracted capsule including the axillary pouch. These structures can be treated by release with arthroscopic instruments.

Operative treatment of adhesive capsulitis has been shown to decrease the duration of the disease and to return ROM with good success. Total recovery of pain-free ROM averages 2.8 months (1–6), and time for formal physical therapy averages 2.3 months (2–20) weeks. Forward elevation improved from the average of 92–165° and external rotation with the elbow at the side improved from 12 to 56° in a series of 68 shoulders treated with arthroscopic capsular release [61].

Patient education

Because adhesive capsulitis is so painful and has a very slow progression of resolution, patient education is critical for success. Patients should be educated in the chronicity of this condition. If they know and understand ahead of time that it can be several years before symptoms are completely resolved, apprehension and a feeling of urgency for functional return may be decreased.

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