ADHESIVE CAPSULITIS

THANATHEP TANPOWPONG ASSISTANT PROFESSOR

CHULALONGKORN UNIVERSITY

“difficult to define difficult to treat

difficult to explain”

Codman

• Codman first define “frozen shoulder”

• 1945 : Nevaiser describe pathological lesion of fibrosis, inflammation and capsular contracture

Prevalence

• 2-3% of population (Female)• 40-60 year• Non-dominant hand• 20-30% involve opposite side

Etilogy

• Unknown– Trauma– Inflammation (TGF-β)

– Associate with diabetes, thyroid dysfunction, Dupuytrens contracture, autoimmune disease, treatment of breast cancer, cerebrovascular accident, MI

Diagnosis

• Primary : idiopathic process, global capsular inflammation and fibrosis

• Secondary : known injury or disesase prior to adhesion

62% of idiopathic adhesive capsulitis were found to have partial thickness tear of supraspinatus

Yoo et al Orthapaedics. 2009;32(1):22

Staging (Neviaser et al CORR 1987)

Symptom Sign Finding

1 pain Full ROM under GA synovitis

2 Severe night pain, early stiff

Stiff (external rotation) Christmas tree synovitis

3 Stiff, pain at end of motion

Significant loss motion Minimal synovitis,loss axillary fold

4 Profound stiff, minimal pain

Motion loss but start to improve

Difficult to identify joint

• Stage 1– Pain, stiff – Gain full ROM after GA or intra-articular

anesthetic injection– Duration 3 month

• Stage 2 (freezing)– Progressive capsular contracture– Limit ROM (not fully recovered)– “Christmas tree appearance”

Acknowledgement to Neviaser AMJ Sport 2010;38:2346

• Stage 3 (frozen)– Progressive loss of motion– Not improve after intraarticular anesthetic

injection – Duration 9-15month

• Stage 4 (thawing)– Minimal pain– Gradual improve ROM– Fully mature adhesion– Difficult to identify intra-articular structure during

arthroscope

Natural history

• No true study of natural history• Self-limiting• Grey: complete recovery in 2 years

• Miller: normal function and minimal pain after home therapy 4 year after home therapy

JBJS Am 1978;60(4):564

Orthopaedics 1996;19(10):849-853

• 94% of idiopathic frozen shoulder recover to normal level, range of motion, function without treatment

Vastamaki et al CORR 2012;470(4):1133.43

TREATMENT

• Address underlying pathology• Treatment according to clinical stage at

presentation

NSAIDs

• Theoretical benefit• No level I or II study to prove effectiveness• Improve pain but not improve motion

• Cox-2 have comparable efficacy compare to Cox-1 ( better night pain control)

Rhind Rhumatol Rehabil 1982;21(1):51-53Duke Rhumatol Rehabil 1981;20(1):54-59

Otha et al. Mod Rhumatolol. Feb 2013

Oral steroid

• Provide rapid relief of pain (similar to intraarticular steroid injection) but not sustain at long term

• Possible long term systemic effects• Not recommend

Buchbinder Ann Rhum Dis 2004;63(11):1460-1469

Intra-articular steroid injection

• Rizk et al : transient (2-3 week) improvement of pain compare to placebo

• Bulgen et al : improve pain and motion in 4 weeks

Arch Phys Med Rehabil 1991;72(1):20-22

Ann Rheum Dis 1984;43(3):353-360

• Van der Windt – 109 patient– 40 mg of triamcinolone vs physical therapy 2/wks– 2.2 injection/6 weeks– Passive joint motion, exercise, ice, hot, electrotherapy– 1 year follow up– Self-assessment and functional score– 77% success in injection group vs 46% in physical

therapy group

BMJ 1998;317(7168):1292-1296

• Intraarticular steroid injection gives better result in early stage of disease

• Stage 1recover in 6 weeks • Stage 2 recover in 7 months

Marx HHS J 2007;3(2):202-207

Physical therapy

• Most consistently prescribe for latter stage

• Cochrane database review– Little overall evidence (4/26)– No evidence that physiotherapy alone is of benefit

in adhesive capsulitis

Cochrane Database Syst Rev 2003;(2):CD004258

• Carette and Bulgen found no difference between physiotherapy and no treatment (control group)—level I study– Low number of participants

Arthritis Rheum 2003;48(3):829-838Ann Rhum Dis 1984;43(3):353-360

• Level I study by Vermeulen– Low grade mobilization have little difference

compare with high grade technique

– Low grade : movement with in pain free zone – High grade: movement into stiff and painful range – “reflex muscle acivity”

Phys Ther 2006;86(3):355-368

Surgical intervention

In most series 10% of patients do not respond to non-operative treatment

Surgical intervention1. Suprascapular nerve blocks2. Hydrodilation3. Manipulation under

anesthesia4. Arthroscopic release5. Open release

• Suprascapular nerve block– Unclear therapeutic mechanism– Disruption of efferent and afferent pain signaling– May normalization pathological and neurological

process

– Insufficient data to prove it’s efficacy

• Hydrodilation (Brisement)– Increase intracapsular pressure until rupture– Compare hydrodilation with MUA

• No diiference in ROM• Better Constant and VAS score

– Small number of trials to proof it’s efficacy

Quraishi JBJS Br. 2007;89(9):1197-1200

Manipulation (MUA)

• MUA vs home exercise (level II)– Slight better moblility at 3 month– No difference in 6 and 12 month

• MUA have effect of improve motion and pain relief for approx 23 years

Kivimaki J Shoulder Elbow Surg 2007;16(6):722-726

CORR 2013;471(4):1245-50

Arthroscopic release

• Advantage– Accurate and complete– Ability to perform synovectomy– Improve mobility of musculotendinous unit

compare with open surgery– Minimal pain– Identify intrinsic pathology– Post operative motion can be done immidiately

• Contraindication – Unable to cooperate postoperative program– Pateint cannot tolerate stress from fluid challenge

(renal or cardiac failure)

Surgical technique

Release rotator interval , SGHL

MGHL

Posterior capsular release

Release axillary pouch and IGHL (multiple perforation or direct cut)

My practice

• Stage 3 or 4 • No intraarticular steroid are injected• Jackin’s exercise (low grade) • Nsaids prior and ice after• If 3-6 month not improve MUA or scope

release

Jackin’s exercise program

• Each 4 position are perform 10 times/round• 5 round/day

• Post operative protocol– Regional nerve block ( interscalene, SSN, brachial) – Immediate post-op : pendulum exercise– Passive stretching ( Forward flexion, IR, ER, ABD)– 2 times/day, 15 minutes/session– Follow up: post-op week 1,2,4,6,8

Thank you