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Anteroposterior radiograph of the left shoulder of a 51-year-old woman with shoulder pain show no arthritis, calcific tendinitis, or other abnormalities.
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Outlet radiograph of the patient’s left shoulder.
A 51-year-old woman presents with a 3- to 4-week history of left shoulder pain. She is also having trouble with motion and feels like her shoulder is getting progressively stiffer. She denies prior injury or known precipitating event. On examination, very limited passive and active range of motion is noted. Forward flexion, abduction, and external rotation are all decreased significantly compared with the contralateral side. Rotator cuff strength is intact. Radiographs show no arthritis, calcific tendinitis, or other abnormalities.
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The patient has adhesive capsulitis or frozen shoulder. The hallmark history and physical examination findings of adhesive capsulitis include spontaneous decrease in both passive and active range of motion.
Pain and progressive decrease in range of motion associated with frozen shoulder is caused by idiopathic thickening of the shoulder capsule and scarring that occurs on the capsule and the humeral neck. The shoulder capsule becomes contracted and range of motion is restricted. The condition most commonly presents in women aged 40 to 60 years and occurs most often in the nondominant arm. Adhesive capsulitis is prevalent in up to 5% of people, but the incidence increases dramatically in those with diabetes who use insulin, with a prevalence of up to 30%.1
Anteroposterior, lateral, and axillary radiographs are commonly ordered for routine evaluation. However, careful physical examination should be adequate to rule out other causes of shoulder pain that have similar presenting symptoms, such as impingement syndrome, rotator cuff disease, and osteoarthritis of the shoulder. If physical examination findings are consistent with adhesive capsulitis, magnetic resonance imaging is not necessary.
First-line treatment for adhesive capsulitis includes intraarticular steroid injection, usually done under fluoroscopic guidance for improved accuracy, which provides pain relief and improved shoulder motion. Physical therapy is initiated after the injection to help the patient regain full range of motion in the shoulder. Pain relief and improved motion usually occur over a period of 3 to 6 months, during which time the patient is supervised with physical therapy. Patients with symptoms beyond 4 to 6 months may require surgery, including manipulation performed with the patient under anesthesia, and/or arthroscopic lysis of adhesions.2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
References
- Griesser MJ, Harris JD, Campbell JE, Jones GL. Adhesive capsulitis of the shoulder: a systematic review of the effectiveness of intra-articular corticosteroid injections. J Bone Joint Surg Am. 2011;93:1727-1733.
- Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg. 2011;19:536-542.
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