Fact-sheet: Adhesive capsulitis


Updated on 09/26/2024 at 9:51 AM

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Definition

Adhesive capsulitis (frozen shoulder) is characterized by shoulder pain and stiffness resulting from inflammation and fibrosis of the shoulder joint capsule.

It is caused by a combination of:

  • Synovitis,
  • Capsular fibrosis: thickening and stiffening of the joint capsule due to myofibroblast proliferation

Clinical features

  • Prevalence = 2-5% of the general population.
  • More common in women
  • Typically occurs between 40 and 60 years of age
  • Usually affects the non-dominant side
  • May affect both shoulders in 20 to 30% of cases

Adhesive capsulitis progresses through three phases spanning one to two years:

  • 1. Painful phase: Pain is the predominant symptom, often severe and present even at night. This phase may last up to three months.
  • 2. Stiffening phase ("frozen shoulder"): Pain gradually decreases, but shoulder stiffness sets in, limiting range of motion, particularly external rotation. This phase may last 3 to 12 months.
  • 3. Recovery phase: Pain and stiffness gradually improve. This phase may last 12 to 42 months, and recovery may be complete or partial

Diagnosis is clinical. Imaging may be useful to confirm the diagnosis and rule out other conditions.

Ultrasound

Hypoechoic fibrovascular tissue at the distal aspect of the rotator interval, often surrounding the long head of the biceps brachii tendon. Possible Doppler hyperemia.

Thickening of the coracohumeral ligament, measuring 3 ± 0.85 mm on average versus 1.34 ± 0.32 mm in healthy subjects.

Other possible sonographic findings:

  • Increased stiffness of the coracohumeral ligament on SWE elastography.
  • Decreased gliding of the supraspinatus tendon beneath the acromion during passive abduction (a relatively subjective sign).
  • Presence of synovial fluid trapped within the sheath of the long head of the biceps brachii

MRI

Rotator interval:

  • Infiltration (or obliteration) of the subcoracoid fat triangle (Sp = 68-100%).
  • Thickening of the coracohumeral ligament >4mm (Sp = 89-95%).
  • Enhancement of the coracohumeral ligament and surrounding tissue.
  • Thickening of the joint capsule at the rotator interval >7mm (on MR arthrography, Sp = 86%).
  • Decreased volume of the rotator interval.
  • Infiltration surrounding the long head of the biceps brachii.

Inferior glenohumeral ligament:

  • T2 hyperintensity of the IGHL compared with the glenoid labrum or the long head of the biceps tendon.
  • Thickening of the IGHL >4mm (Sp 95%), though controversial in the absence of joint distension.
  • Presence of a thin T2-hyperintense band within the fat adjacent to the IGHL (Sp 70%).
  • Enhancement of the IGHL and surrounding tissue.
  • Decreased volume of the axillary recess on MR arthrography.

Other MRI findings:

  • Signal abnormalities of the humeral head: predominantly subchondral "edema-like" signal in the humeral head, and/or a punctate appearance related to osseous rarefaction.
  • Fluid distension of the subscapularis recess or the bicipital sheath by synovial fluid
  • Synovitis of the axillary recess, the rotator interval, and the subscapularis recess
  • Subacromial-subdeltoid bursitis

Vascular intervention

Capsular distension with 1% lidocaine + intra-articular corticosteroid injection + ultrasound-guided suprascapular nerve block via posterior approach.

  • 3 procedures performed 1 week apart,
  • combined with physical therapy immediately following the procedures.