Adhesive capsulitis (frozen shoulder) is a lesion of the capsule of the shoulder joint, accompanied by significant restriction of movement. The joint itself is not involved in the process. The disease proceeds in stages: at first there are pains, then – restriction of movements, after which the functions of the limb are gradually restored. Recovery occurs in 1.5-4 years from the moment of the first symptoms. The diagnosis is established on the basis of anamnesis, complaints and objective examination data, instrumental and laboratory techniques are prescribed to exclude other pathologies. Conservative treatment: drug therapy, stretching of the joint capsule, restriction, and then an increase in the load.
ICD 10
M75.0 Adhesive Shoulder Capsule
General information
Adhesive capsulitis is a disease that causes severe impairment of limb functions and causes prolonged disability, but has a favorable prognosis and ends with recovery. It is diagnosed in about 2% of the population. Usually occurs at the age of 50-70 years, women suffer 3-5 times more often than men. Equally often affects the dominant and non-dominant hand. In 7-10% of patients, the adhesive process is bilateral in nature, symptoms in the area of the second shoulder appear within a period of several months to several years from the moment of the onset of the disease.
Causes
The causes of adhesive capsulitis have not yet been established. Researchers believe that the disease is provoked by trophic disorders caused by disorders of nervous regulation. Experts suggest that the disease is etiologically related to pathologies that occur against the background of reflex tissue dystrophy, in particular, Zudek syndrome, which often develops simultaneously with capsulitis (shoulder-hand syndrome).
Adhesive capsulitis can form independently or be provoked by other diseases. The conditions that most often cause fibrosis of the capsule include:
- diabetes mellitus;
- malignant neoplasms;
- hyperthyroidism;
- stroke and myocardial infarction;
- condition after heart surgery.
The most common cause of the secondary adhesive process is type II diabetes mellitus – the disease is determined in every third diabetic. The relationship between capsulitis and tendinitis (the most common pathology that causes shoulder pain) is not confirmed by research data.
Pathogenesis
A gross violation of the function of the shoulder joint in patients with adhesive capsulitis is caused by severe fibrosis of the capsule and a decrease in the articular cavity. In the early stages, moderate inflammation occurs, the composition of the tissues changes. The inflammatory process and the restructuring of the capsule are accompanied by pain syndrome. Gradually, the articular membrane “shrinks”, its parts stick together.
The lower inversion is completely obliterated. The volume of fluid that can be injected into the joint cavity decreases from 25-30 to 5-10 ml. There are no signs of inflammation at this stage. A large number of fibroblasts and mature fibrous tissue are detected in biopsies. Areas of thickening appear in the area of the capsule and synovial membrane.
Classification
Adhesive capsulitis is characterized by a pronounced stage course with a gradual change in symptoms. In modern orthopedics , there are three phases of the disease:
- Painful. It takes 3 to 12 months. It is accompanied by a pain syndrome and a gradual decrease in the volume of movements.
- Rigor mortis. The duration is approximately equal to the previous stage. Pains decrease and disappear, movements are sharply limited.
- Thawing. The duration is 1-2 years. Movements are gradually restored, although in some cases they do not reach the volume that was before the onset of the disease.
The duration of each phase and the total duration of capsulitis are determined by many factors, including the beginning of treatment, the presence of concomitant pathologies, etc. Usually, the time intervals during which each stage continues are proportional to each other. If the painful phase has been going on for a long time, rigor mortis and thawing will also be prolonged.
Symptoms
Pain appears for no apparent reason, less often occurs after overload or minor injury. Gradually increase over 1-3 weeks, then begin to disturb at night. The patient wakes up from the pain, cannot sleep on the side of the lesion. Against the background of pain syndrome, mobility is limited, and not immediately in all directions, but in a certain sequence.
Initially, the range of motion decreases when the arm is turned outward. At the same time, but to a lesser extent, the diversion is limited. Then there are problems with the rotation of the shoulder inside. Difficulties are noted when performing ordinary household actions – eating, washing, combing, dressing and undressing, turning the key in the keyhole. After a few months, the joint is almost completely blocked.
The pain syndrome persists, sometimes combined with swelling and impaired mobility of the distal extremities (hands and wrists). Debilitating pain and disability stimulate patients to seek medical help, but the diagnosis of adhesive capsulitis is often difficult due to the absence of pathognomonic symptoms.
In the phase of rigor mortis, the pain gradually decreases, practically disappears at rest and appears only when trying to move in the shoulder joint. Movements are still severely restricted. The ability to work has been lost. On average, after 7-8 months, the range of movements gradually begins to increase, the process continues in the thawing phase until complete or almost complete recovery.
Complications
Despite the pronounced clinical symptoms that cause temporary disability, adhesive capsulitis proceeds favorably and does not cause complications. Negative consequences are possible with improper treatment or the patient’s uncertainty about the outcome of the disease. Too long or constant immobilization potentiates insufficient recovery of functions and the development of stiffness. Disability with unclear prospects provokes the development of neurotic disorders.
Diagnostics
The diagnosis is made by orthopedic doctors or rheumatologists. Diagnosis is based on anamnestic data and the results of a physical examination. The only informative instrumental method is arthrography, but in clinical practice it is almost not used because of its invasiveness and a sufficient amount of clinical information. Taking into account the phase , an objective examination reveals:
- Phase 1. The deltoid muscle on the affected side is reduced in volume. Palpation determines the diffuse soreness in the area of the shoulder joint. Active and passive movements are equally limited – this feature allows you to differentiate adhesive capsulitis with other pathologies with similar symptoms.
- Phase 2. Muscle hypotrophy becomes more pronounced. Passive and active movements are limited to the same extent, but now – because of a mechanical obstacle. Pain is absent or weakly expressed.
- Phase 3. The degree of restoration of joint function varies significantly depending on the time that has elapsed since the beginning of the phase. The diagnosis is confirmed on the basis of a characteristic anamnesis, the patient reports that the shoulder initially hurt, then did not move, now it is “being developed”.
Adhesive capsulitis is differentiated with arthritis, rheumatic polymyalgia, chondromatosis, aseptic necrosis of the shoulder head, Milwaukee syndrome and malignant tumors. In the course of differential diagnosis, an analysis for C-reactive protein is prescribed, ESR is determined, and radiography is performed. According to laboratory studies, there are no changes, osteoporosis can be detected on radiographs with a long course.
Adhesive capsulitis treatment
Treatment is carried out on an outpatient basis, determined by the stage of pathology. An important part of therapy is the formation of the patient’s confidence in a successful outcome, which allows avoiding the development of neurotic disorders. Therapeutic measures for primary and secondary forms of the adhesive process are identical, the only difference is the restriction of hormonal drugs in diabetes mellitus.
Treatment in the pain phase
The main goal of adhesive capsulitis therapy in this period is to reduce pain syndrome. Treatment includes medication and non-medication measures:
- Protective mode. The load on the shoulder joint is limited. Immobilization is dosed to prevent the development of stiffness. In case of intense pain, it is recommended to use a kerchief bandage for no more than a few hours daily.
- NSAIDs. Nonsteroidal drugs are prescribed in tablets in a daily dose of no more than 200 mg. The duration of administration and the dose are determined taking into account the severity and duration of the pain syndrome. The medicine of choice is aceclofenac, which is better tolerated than other drugs of this group and does not accumulate in the body, which is important in the treatment of older people.
- Hormonal agents. Intra-articular blockades with glucocorticoids are performed as early as possible, since this allows to shorten the duration of the pain phase of capsulitis. If the pain resumes, the procedure is repeated after 2-3 weeks. The course of treatment includes no more than 3 blockades.
If the above methods are ineffective or it is impossible to use hormonal drugs in patients with diabetes mellitus, intra-articular injections of medications based on hyaluronic acid are used, blockades of the supra-scapular nerve are carried out. Physiotherapeutic methods for patients with adhesive capsulitis are usually not indicated due to insufficient effect. It is possible to prescribe electrophoresis with novocaine to reduce pain.
Treatment in the phases of rigor and thawing
After reducing the intensity of the pain syndrome, the protective regime and drug therapy are canceled. The main emphasis is on intensive development and stretching of the joint capsule. The patient is taught exercises that need to be performed for several months. Special simulators are used for metered stretching.
Redressation is rarely performed, the indication for active surgical mobilization is the absence of an increase in the volume of movements for six months or more after the start of the second phase of the adhesive process, if the patient wishes to accelerate recovery. Sometimes partial mobilization is carried out using arthroscopic equipment. With symptoms of synovitis, arthroscopic synovectomy is possible.
Prognosis and prevention
The prognosis for adhesive capsulitis is favorable, after the completion of the thawing phase in half of the patients, movements are restored in full. In the second half of patients, there is a slight restriction of function in the outcome, which does not affect the ability to work and self-care. Preventive measures have not been developed due to the ambiguity of the etiology of the disease.