Adhesive Capsulitis

Adhesive capsulitis is classified as a primary or secondary disorder. The cause of primary capsulitis is not known and has a gradual onset. It typically begins with inflammation and leads to scarring, thickening and shrinking of the capsule that surrounds the shoulder joint. It is associated with diabetes, thyroid diseases (both hyperthyroidism and hypothyroidism), drugs, cardiovascular disease, Parkinson’s disease and cervical spondylosis- age-related cervical disc degeneration. Secondary adhesive capsulitis usually results from shoulder trauma, rotator cuff injuries and tears, fractures and surgery or prolonged immobilization.

Adhesive capsulitis progresses from the freezing stage to the thawing stage.

• In the freezing stage the shoulder becomes stiff and shoulder pain is disabling and is worse at night. This stage can last from 8 weeks to 9 months.
• In the frozen stage, the pain might begin to diminish but the shoulder becomes stiffer, and using it becomes more difficult. This stage generally lasts 4 to 12 months.
• The thawing stage is when the range of motion in the shoulder begins to improve. This final recovery phase can take 12 months to 2 years to restore full shoulder movement.

The diagnosis of adhesive capsulitis, or frozen shoulder, is primarily based on a clinical examination and the patient’s history. Dr. Patel will evaluate your symptoms and medical history to evaluate risk factors. He will test the shoulder’s active and passive range of motion including performing specific tests to check for restrictions in movement. Active range of motion is where you move the shoulder. Passive range of motion is when the doctor tests the shoulder’s range of motion. In adhesive capsulitis, the passive range of motion is also limited, distinguishing it from other conditions where only active movement is restricted. He will examine both shoulders and compare their range of motion.

While adhesive capsulitis is primarily diagnosed through physical examination, imaging tests may be employed if there is concern about an alternative diagnosis, or to rule out other causes of shoulder pain and stiffness, such as arthritis or a rotator cuff tear.

• X-rays can eliminate other causes of shoulder pain, such as bone spurs or arthritis.
• Magnetic Resonance Imaging (MRI) and Ultrasound are less commonly used for diagnosing adhesive capsulitis but can help identify other shoulder problems or confirm the diagnosis if the clinical examination is inconclusive.
• An injection test can be used when the diagnosis is uncertain. In this test, the shoulder is injected with lidocaine. When the range of motion limitations and discomfort persist after injection the diagnosis will be confirmed. 

The focus of treatments are to alleviate pain and restore range of motion. Initially, treatment is conservative involving over the counter medications such as NSAIDS and physical therapy.

Oral corticosteroids can provide short term pain relief for improved function, but the benefits don’t last more than a few weeks, and side effects are considerable. Steroid injections have been shown to improve reduce pain but have considerable risks including intraarticular placement of the steroid and side effects, particularly in diabetic patients.

A procedure called Hydrodilatation may be used. Here the affected shoulder joint is injected with a combination of saline and steroid to promote dilation of the capsule- sterile water into the joint capsule can stretch the tissue, potentially improving range of motion. This is a procedure and has to be performed in an procedure room.

Emerging research suggests that low-level laser therapy (LLLT) offers an effective alternative for managing this condition.  This treatment option avoids the negative effects and risks of corticosteroid injections. LLLT also known as photobiomodulation therapy, is a non-invasive treatment option gaining attention for its potential benefits in managing adhesive capsulitis. LLLT has been shown to reduce pain and inflammation in patients with adhesive capsulitis. By stimulating the release of endorphins and modulating inflammatory processes, LLLT can provide relief from the discomfort associated with this condition.  This is typically started 1-2 weeks prior to physical therapy to allow for adequate pain and inflammation control prior to capsular mobilization in PT.

When conservative measures fail to provide symptom relief, Dr. Patel may recommend arthroscopic capsular release. This minimally invasive surgical procedure is performed under general anesthesia. The goal is to relieve the stiffness and pain associated with frozen shoulder by cutting through tight portions of the joint capsule. Dr. Patel will make several small incisions and insert an arthroscope, a thin tube equipped with a camera and light. This allows him to view the inside of the shoulder joint on a monitor. Using specialized instruments, he will carefully cut through the tight and thickened parts of the joint capsule to release the tension and increase the range of motion. He may also remove any scar tissue (adhesions) that has developed within the joint and around the shoulder muscles to further improve mobility. The incisions are closed with sutures, and you will wake with the shoulder in a sling.

Note that in certain circumstances, arthroscopic capsular releases may not be appropriate.

After the surgery, a period of rehabilitation is crucial to regain strength and mobility in the shoulder. The postoperative rehabilitation process may include:

• Rest and Ice to reduce swelling and pain.
• Physical therapy begins early with a focus on gentle stretching, gradually progressing to more extensive range of motion exercises and later to strengthening exercises.

Arthroscopic capsular release is an effective treatment for adhesive capsulitis when conservative treatments have failed. It offers a minimally invasive option with the potential for a significant improvement in shoulder function.