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Natural history of adhesive capsulitis is not completely understood
In a comparison of intra-articular and intrabursal injections, there was no difference in pain relief.
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This month’s 4 Questions interview is about adhesive capsulitis of the shoulder. There is considerable treatment variation among orthopedic surgeons, from those who believe nothing other than time and gentle exercises make a difference, to those who are more aggressive with various interventions. I have asked Grant L. Jones, MD, to share his insight and approaches to this frequently seen condition in an orthopedic practice.
Douglas W. Jackson, MD
Chief Medical Editor
Douglas W. Jackson, MD: What is adhesive capsulitis?
Grant L. Jones, MD: Adhesive capsulitis is characterized by the spontaneous onset of shoulder pain and global limitation of both active and passive range of motion. It affects 2% to 5% of the outpatient population. In patients with insulin-dependent diabetes mellitus (IDDM), the prevalence reaches 30%. The pathogenesis remains unclear, but it has been associated with female gender, age greater than 40 years, IDDM, thyroid disorders, prolonged immobilization, stroke, myocardial infarction and autoimmune disease. Adhesive capsulitis typically passes through three phases: stage I or “freezing” stage, which consists of increasing pain and stiffness lasting for a period of up to 9 months; stage II or “frozen” stage, which involves a steady state in which there is minimal pain and persistent loss of motion; and stage III or “thawing” phase, which is a period of spontaneous recovery lasting 5 months to 24 months.
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Jackson: What is known about its natural history?
Jones: Although typically described as a self-limiting disease process, the natural history of adhesive capsulitis is not completely understood. Regardless of treatment, most patients achieve maximal outcome between 2 years to 4 years after treatment. However, some studies have shown that some patients have persistent loss of motion, inability to perform activities of daily living and mild pain and weakness at long-term follow-up (as long as 7 years).
Due to the potential for this disorder to have a prolonged recovery and long-term residual pain and restriction of motion, many nonoperative and operative interventions have been described to hasten its course, improve subjective and objective long-term outcomes. These include the use of NSAIDs, physical therapy, corticosteroid injections, viscosupplement injections, hydrodilation, manipulation under anesthesia (MUA), and arthroscopic or open lysis of adhesion.
Jackson: What did you discover from your literature review regarding the effectiveness of intra-articular steroid injections?
Jones: We performed a systematic review of the literature to evaluate the effectiveness of intra-articular corticosteroid injections for the treatment of adhesive capsulitis. We evaluated the existing level 1 and 2 evidence comparing corticosteroid injections and all other standard treatments.
Eight studies comprising 406 patients (409 shoulders) met our inclusion criteria. We found that all treatments of adhesive capsulitis resulted in improved clinical outcome measures. Most treatments resulted in improved passive range of motion (ROM) at the time of early follow-up, with both intra-articular steroid and oral steroid showing significantly greater improvements in abduction and forward elevation as compared to intra-articular lidocaine and intra-articular saline.
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Image: Jones GL |
These significant improvements did appear to be transient, as all treatments resulted in improved passive ROM at the time of latest follow-up, with no treatments having a statistically significant advantage. Pain was significantly reduced at both short-term and long-term follow-up with intra-articular steroid, oral corticosteroid, MUA, hydrodilation and physical therapy. The only significant difference in pain scores between these groups was intra-articular steroid with and without physical therapy having lower pain scores than a saline-based placebo control injection. However, there was no difference in longer term outcome. It was of interest, in a comparison of intra-articular and intrabursal injections, that there was no difference in pain relief or shoulder motion.
Jackson: Based on your experience and review of the literature, what is your approach to treating this condition?
Jones: If a patient presents in the painful freezing stage, I regularly perform an intra-articular corticosteroid injection. If the patient has diabetes, I make sure that his or her diabetes is well-controlled. If the diabetes is not under good control, then I will delay the injection. An intra-articular steroid both decreases the pain and expedites the recovery of ROM.
If a patient presents in an established frozen stage, I find that intra-articular steroid injections are less helpful. In this case, I will start the patient in a gentle physical therapy program and allow the disease to run its course. It is important to educate the patient that the disease may take several months to resolve and that the “thawing” process can be gradual.
If the patient presents in a prolonged frozen stage more than 6 months to 9 months and is a person at risk for recalcitrant adhesive capsulitis (i.e., insulin-dependent diabetic), I consider proceeding with a MUA and arthroscopic lysis of adhesions. During the procedure, I perform a gentle manipulation in forward elevation to release the inferior capsule. I then proceed with a shoulder arthroscopy with lysis of adhesions. I first release the rotator interval and then release the rest of the anterior capsule down to the inferior capsule, which was released with the manipulation, to regain external rotation. Next, I release the posterior capsule just off its glenoid insertion to regain internal rotation. Postoperatively, the patient uses a continuous passive motion machine at home and starts physical therapy immediately.
Reference:
- Griesser MJ, Harris JD, Campbell JE, Jones GL. Adhesive capsulitis: A systematic review of the effectiveness of intra-articular corticosteroid injections. J Bone Joint Surg Am. 2011;93:1727-1733.
- Grant L. Jones, MD, can be reached at The Ohio State University, OSU Sports Medicine, 2050 Kenny Rd., Suite 3100, Columbus, OH 43221; 614-293-3600; fax: 614-293-4399; email: grant.jones@osumc.edu.
- Disclosure: Jones has no relevant fianancial disclosures.