Adhesive Capsulitis: Causes, Symptoms, and Remedies
Adhesive capsulitis is a condition in which the capsule that holds the shoulder joint become thickened due to inflammation and scarring. It is also known as Frozen Shoulder. This condition is characterized by pain, stiffness and gradual loss of active and passive range of motion (ROM) of shoulder.
Adhesive capsulitis occurs in three phases:
Freezing phase: This is the initial phase, in this shoulder becomes painful and stiff. The joint capsules become inflamed due to inflammatory mediators such as cytokines. These mediators also trigger nociceptors (pain receptors).
Frozen or stiffening phase: This phase is less painful. The inflamed areas slowly start developing scar tissue. Fibrotic scar tissue starts to accumulate around the joint capsule which causes joint stiffness.
Thawing or recovery phase: No inflammatory mediators are released, therefore no activation of nociceptors. After some months, scar tissue breakdowns by itself and gets replaced by healthy tissue. In this phase pain decreases and shoulder movement gradually improves.
Types and their Causes
Adhesive capsulitis can be classified into two types based on the underlying cause:
- Primary: The etiology is unknown, but this type is commonly seen in patients with diabetes and hypothyroidism.
- Secondary: It can occur due to injury or prolonged immobility. An example of shoulder injury is rotator cuff tendinopathy. Prolonged shoulder immobility may be due to hemiplegia or paralysis on one side of the body.
Needle-like pain is the major symptom of adhesive capsulitis. The pain initially starts in the outer part of the shoulder and over the period, pain radiates to the elbow and forearm. However, the condition is self-limiting and resolves within 6 months to 2 years. Symptoms appearing in different phases are:
Freezing phase: It lasts for 2 to 9 months.
- Shoulder pain that worsens at night
- Joint stiffness
- Sleep is affected as the person cannot sleep on the affected side.
Frozen phase: It lasts for 4 to 12 months.
- Continuously accelerating pain
- Decreased range of motion in all planes
Thawing phase: It lasts for 8 to 24 months
- Gradual decrease in pain
- Gradual improvement in range of motion
The major predisposing factor of adhesive capsulitis is history of diabetes mellitus. Patients with type 1 diabetes mellitus or insulin dependent diabetes are more prone to it when compared to patients with type 2 diabetes mellitus. It occurs mostly in the people between the age group of 40 and 60. Other factors that increase the risk of adhesive capsulitis are:
- Hypothyroidism or hyperthyroidism
- Parkinson disease
- Cerebrovascular or brain stroke
- Heart diseases
- Hyperlipidemia or high cholesterol levels
- History of shoulder injury or surgery
Diagnosis and Treatment
The healthcare provider obtains the medical history and examines the shoulder. During the physical exam, the healthcare provider may ask the patient to move the shoulder in various directions for evaluation of shoulder ROM. The doctor would also passively move the shoulder joint to check for movement restriction.
If adhesive capsulitis is suspected, further tests may be recommended to confirm the diagnosis and rule out other causes of shoulder stiffness such as osteoarthritis and joint dislocation. Imaging tests such as X-rays can help to check for symptoms are not because of another problem with the shoulder, such as arthritis.
The main goals of therapy of adhesive capsulitis are to decrease pain and inflammation and improve shoulder ROM.
- Cold compress: It can help to reduce pain and inflammation. Physiotherapy can also help in speeding up the breakdown of scar tissue and exercises prescribed by physio can help to reduce pain, stiffness and improve joint ROM.
- Intra-articular injection (injection into the joint): Corticosteroids injections can help to reduce pain and inflammation and improve mobility. Usually, these injections can help patients who are in the freezing and frozen phases.
- Surgery: It is recommended in later stages, when there is no improvement with the above-mentioned treatments even after 4 to 6 months. There are two types of surgeries available for treating adhesive capsulitis
- Closed manipulation under anesthesia: In this procedure, the patient is kept under anesthesia and procedures such as shoulder mobilization, traction and manipulation are done. This helps in breaking down scar tissue in the capsule.
- Arthroscopic capsular release: In this therapy, anesthesia is given, and an arthroscope is inserted into the joint by making small incisions. With the help of the device, the scar tissue is broken down using tiny instruments
Performing exercises at home is essential to improve full ROM of shoulder and prevent further loss of function. A physiotherapist will guide you about the exercises to be performed. Exercises that can be performed include:
- Pendulum exercises
- Overhead stretches
- Crossed addiction
- Finger walk on the wall
- Armpit stretches
It is mandatory to be compliant with the exercises program. If it is difficult for you to perform physical activities, seek medical attention for further evaluation.
Preventing the injuries to the shoulder if you are at risk is the best measure to prevent adhesive capsulitis.
- Perform shoulder exercises as advised by the healthcare provider after shoulder surgery or stroke.
- Consult a healthcare provider if you are finding difficulty to move the shoulder in full ROM as early diagnosis can help in preventing stiffening of the shoulder.
1. What are the alternative therapies for treating frozen shoulder?
Acupuncture and transcutaneous electrical nerve stimulation (TENS) are two therapies that help in treating frozen shoulder.
2. Which drug can I take to manage pain due to frozen shoulder?
You may take anti-inflammatory drugs like ibuprofen, naproxen, or aspirin to manage pain due to frozen shoulder. However, it is recommended to consult your physician before taking any medicine.
3. How long will frozen shoulder take to recover without surgery?
The complete recovery of frozen shoulder may take up to 3 years.
4. Which exercise helps in treating frozen shoulder?
Stretching exercises like pendulum stretch, towel stretch, cross-body reach, finger walk, outward rotation, armpit stretch, and inward rotation helps in treating frozen shoulder.
5. How does transcutaneous electrical nerve stimulation (TENS) work?
A. TENS block the pain fibers that carry pain impulse or stimulate the release of endorphins (pain-inhibiting molecules).