Adhesive Capsulitis of the Hip: Clinical Features, Diagnosis, and Management

Addition of Intra-articular Hyaluronate Injection to Physical Therapy Program Produces No Extra Benefits in Patients With Adhesive Capsulitis of the Shoulder: A Randomized Controlled Trial

Adhesive shoulder capsulitis, or arthrofibrosis, describes a pathological process in which the body forms excessive scar tissue or adhesions across the glenohumeral joint, leading to pain, stiffness and dysfunction. It is a debilitating condition that can occur spontaneously (primary or idiopathic adhesive capsulitis) or following shoulder surgery or trauma (secondary adhesive capsulitis). Here, we review the pathophysiology of adhesive shoulder capsulitis, highlighting its clinical presentation, natural history, risk factors, pathoanatomy and pathogenesis. Both current non-operative and operative treatments for adhesive capsulitis are described, and evidence-based studies are presented in support for or against each corresponding treatment. Finally, the review also provides an update on the gene expression profile of adhesive capsulitis and how this new understanding can help facilitate development of novel pharmacological therapies.

Background: Adhesive capsulitis is a condition characterized by pain and restricted range of motion (ROM) in the shoulder joint. Type 2 diabetes mellitus has been associated with an increased incidence of adhesive capsulitis, potentially exacerbating shoulder dysfunction. The objective of this study is to assess the ROM in the shoulder joints of patients with adhesive capsulitis and type 2 diabetes mellitus. Materials and methods: This cross-sectional observational study was carried out in the outpatient department of Physical Medicine and Rehabilitation, Dhaka Medical College and Hospital (DMCH), Dhaka from July 2021 to June 2022. A total of 122 diabetic patients with adhesive capsulitis attending the study place were selected by purposive sampling. Patients with a history of trauma, surgery, neurological conditions affecting shoulder, rheumatoid arthritis, thyroid disorders, pain or disorders of cervical spine, elbow, wrist or hand and rotator cuff rupture and tendon calcification were excluded from the study. The patient’s pain was recorded using the visual analogue scale (VAS). Movements of the affected shoulder joint were measured by using a goniometer. The validated Bangla version of Shoulder Pain and Disability Index (SPADI) was used to assess functional status. Variables were expressed as mean ± standard deviation (SD), frequency and percentage. Results: The mean age of the patients was 51.9 ± 8.6 years. In this study 74 patients (61%) had adhesive capsulitis on their right shoulder and the rest 48 (39%) had adhesive capsulitis on their left shoulder. The mean flexion, extension, abduction, internal rotation and external rotation was 99.9±20.2, 39.5±11.7, 94.9±20.3, 34.7±15.0 and 53.7±12.6 respectively. There was a significant positive correlation between blood glucose level and pain score in VAS and SPADI. However, there was no significant correlation between blood glucose level and range of motion of patients. There was no significant correlation between duration of diabetes and pain, range of motion and functional impairment of patients in this study. Conclusion: Adhesive capsulitis in Type 2 diabetic patients is associated with greater limitations in shoulder range of motion. Poor glycemic control might exacerbate the severity of shoulder dysfunction, highlighting the importance of managing blood sugar levels in this patient to prevent further mobility impairment. Eastern Med Coll J. July 2025; 10 (1): 76-80

Introduction •Adhesive capsulitis of the shoulder or frozen shoulder is a debilitating condition characterized by progressive pain, stiffness and limited range of motion about the glenohumeral joint, the term (adhesive capsulitis) to describe the findings of chronic inflammation and fibrosis of the joint capsule, characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder. (Zhao W, ZhengX, liu Y, et al.,2012). •MRI has, in recent years, allowed for the visualization of several characteristic signs seen with this condition, including thickening and shortening of the coracohumeral (CHL) ligament, thus limiting external rotation is due to fibroblastic proliferation within the CHL, thickening of axillary pouch and rotator interval joint capsule, in addition to the obliteration of the subcoracoid fat triangle.(Cheng X, et al.,2017). Aim of the work to examine the association between clinical features (stages) and MRI findings in adhesive capsulitis of the shoulder. Methods and material seventy patients confirmed or suspected adhesive capsulitis of the shoulder. The diagnosis is based on MRI findings and clinical criteria. Patients who complain from shoulder pain and restricted ROM with detailed clinical information and history which permit the clinical staging of AC and patients with normal ROM in the opposite shoulder are also included (the initial diagnosis was based on the history and clinical symptoms) clinical criteria for the diagnosis of AC includes: restricted passive motion for greater than 30 degrees in the two or more planes of movement, gradually increasing shoulder pain that was more severe at rest at least 1 month duration, and normal radiographic findings .Patients who fullified these criteria underwent shoulder MRI to correlate MRI findings with pain intensity, range of motion and clinical stage. Study is approved by the ethics review board of Ain Shams University Hospital. For the MRI examination, (a 1.5 tesla Philips Healthcare) MRI machine at El-Demerdash University Hospitals with a dedicated shoulder surface phased –array coil. During imaging, patients were in supine position .MRI protocol consisted of the following sequences:Fat-suppressed T2: coronal oblique, sagittal and axial weighted images, proton density(PD), fast spin echo T1-Weighted sagittal images.All patients will be subjected to complete history taking, full clinical examination. All MRI imaging examinations were conducted at radiology department of Ain Shams University. All patients were subjected to full history taking prior to scanning and full clinical examination. Results Regarding the diagnostic performance of shoulder MRI there is a statistically significant difference between degree of pain intensity according to Capsular thickening regarding humeral “mm” with p-value (p < 0.05). The highest value was found moderate and severe pain group (5.67±1.39) compared to absent, minimal & mild pain group (4.42±1.29)., there was a statistically significant difference between two groups according to axillary recess regarding height “mm” with p-value (p < 0.05). The highest value was found absent, minimal & mild pain group (7.02±2.68) compared to moderate and severe pain group (5.73±2.25). There is no statistically significant association between pain intensity and MRI finding regarding Capsular Edema, Extra Capsular Edema, Obliteration of Subcoracoid Fat Triangle, Effusion of Biceps Tendon Sheath, Capsular Thickening Glenoid (mm) and Axillary Recess Width (mm), with p-value (p > 0.05 NS). •Qualitative and quantitative analysis a highly statistically significant difference between absent and present of limitation of ROM “abduction” according to Capsular Thickening Glenoid (mm) with p-value (p < 0.001). The highest value was found absent group (6.29±0.99) compared to present group (5.21±1.39). •Additionally, the results showed 25 patients out of 70 having extra capsular edema anterior, 20 patients (48.8%) belong to absent abduction group and 5 patients (17.2%) belong to present abduction group, as there was a statistically significant negative relation with p-value (p = 0.014). •There is no statistically significant association between absent and present of limitation of ROM “abduction” and MRI finding regarding Capsular Edema Glenoid, Capsular Edema Humeral, Extra Capsular Edema Posterior, Obliteration of Subcoracoid Fat Triangle, Effusion of Biceps Tendon Sheath, Capsular Thickening Humeral (mm), Axillary Recess Height (mm) and Axillary Recess Width (mm), with p-value (p > 0.05 NS) Conclusion MRI can be useful for assessment several measures of clinical impairment in patients with adhesive capsulitis . thickening and hyperintensity of the joint capsule in the axillary recess on MRI is associated with limited ROM and duration of symptoms.

IntroductionShoulder injury related to vaccine administration (SIRVA) is a group of pathologies defined by pain and stiffness after intramuscular administration of vaccine to the upper arm and has been reported after COVID-19 vaccination. We aim to discuss its pathophysiology, clinical presentation, treatment and outcomes.Materials and methodsWe retrospectively identified patients presenting with adhesive capsulitis within four weeks of administration of COVID-19 vaccine to the affected arm at our tertiary institution from March 2021 to December 2022.ResultBased on the above criteria, we identified seven cases of adhesive capsulitis, comprising one male and six female patients, with average age of 60 years. We present initial symptoms, signs and the duration from when the vaccine was administered. We have highlighted our treatment strategies as well as the clinical and functional outcomes reported by these patients after treatment. We have reported improvement in both Visual Analogue Scale (VAS) and range of motion (ROM) in all our patients after non-surgical management which included physiotherapy and, in some cases, hydrodilatation.ConclusionSIRVA related adhesive capsulitis is rare and under-reported with limited information in current literature. This study highlights that adhesive capsulitis is a potential complication arising from improper COVID-19 vaccine administration and reinforces traditional wisdom of administering vaccinations on the non-dominant arm. Conservative treatment strategies appear to be effective, particularly hydrodilatation combined with physiotherapy, and patients are expected to have a good return of function.

Background: Adhesive capsulitis is a condition characterized by stiffness and pain in your shoulder joint. Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one to three years. A total number of 50 subjects fulfilling the inclusion criteria were included in the study, consent was obtained from them. They were divided into two groups conveniently as Group A (MWM) and Group B (SM) with 25 subjects in each group. Hot pack and pendulum exercise were given for both the groups. Pre and post treatment measurements were taken on Day 0 and Day 21 by using SPADI pain subscale(%) for measuring pain and gleno-humeral active flexion and external rotation range of motion by a standard goniometer for both group A and group B subjects. The data were recorded and statistically analyzed using PASW version 21.0. An alpha level of 0.05 was used to determine statistical significance. Results: The SPADI pain subscale score (%) and GH-AROM across pre-intervention and post-intervention showed a significant improvement statistically in their mean scores within Group A and Group B (p= 0.000). Statistically significant greater change in score were found in MWM (Group A) for AROM (Flexion and ER) and SPADI pain score (%) as compared to SM (Group B) [p value= 0.000]. Conclusion: This study shows that MWM and SM both are effective in reducing pain and improving flexion and external rotation range of motion in adhesive capsulitis of shoulder. But when compare both the techniques MWM is more effective than SM in 3 weeks. Keywords: Adhesive capsulitis, mobilization with movement, scapular mobilization, SPADI, AROM, hot packs, pendulum exercise, goniometer Cite this Article Bhatri Pratim Dowarah, Lipika Boruah. A Comparative Study to See The Effect of Mobilization with Movement and Scapular Mobilization to Reduce Pain and to Improve Gleno-Humeral Range of Motion in Adhesive Capsulitis of Shoulder. Research & Reviews: Journal of Neuroscience. 2016; 6(2): 11–18p.

Circumferential Arthroscopic Capsular Release: Reflections and a Historical Perspective

BackgroundThis study aimed to evaluate the response rate to arthroscopic release treatment in adhesive capsulitis of the shoulder (ACS) for patients with refractory to conservative treatment.MethodsIn this retrospective study, 51 patients (age mean, 49.1±5.6 years) with unilateral adherent capsule underwent arthroscopic releasing surgery for the shoulder capsule. Etiologies of the ACS in 30 patients were idiopathic: 10 patients were affected after surgery and 11 patients following trauma. The patients were evaluated in terms of shoulder function, satisfaction rate, pain intensity, and joint range of motion (ROM) based on a Constant score, a Simple Shoulder Test, the visual analog scale, and four movements, respectively.ResultsThe mean Constant score before surgery was 48.2±3.5 and reached 74.4±6 and 77.0±6.3 at 6 months and the final follow-up, respectively (p<0.001). The mean scores of pain intensity, a Simple Shoulder Test, and ROM showed significant improvement at all follow-ups (p<0.001). Sex, age, and diabetes did not have any significant effect on patient recovery. However, patients who experienced ACS after surgery had poorer results than others at all follow-up points.ConclusionsArthroscopic releasing surgery of the shoulder in patients with ACS refractory to conservative treatment produces rare complications and an effective injury response. It seems that patients suffering ACS following surgery have a weaker response to the treatment.

The article presents a current view of the etiology and pathogenesis of, adhesive capsulitis of the shoulder joint and the basic principles of conservative and surgical treatmen. Idiopathic adhesive shoulder capsulitis is a self-limiting disease with gradual improvement in symptoms, sometimes demanding surgical treatment. Currently, the role of both inflammatory and fibrotizing processes in the pathogenesis of adhesive capsulitis is generally recognized, when the inflammatory process ultimately leads to fibrotic changes. The disease is associated with diabetes mellitus, thyroid disease, cerebrovascular disease, coronary heart disease, autoimmune diseases, and Dupuytren’s contracture. In theliterature there isno consensus on the unified treatment modality for adhesive capsulitis: conservative, operative, or combined. In a number of patients, improvement is achieved spontaneously, the recommended methods of treatment range from follow-up to invasive open capsulotomy. There is no universal treatment algorithm, so treatment should be individualized. By all accounts, conservative treatment is the first treatment of choice for adhesive capsulitis and includes physical therapy in combination with physiotherapy, anti-inflammatory drugs, corticosteroid injection, and hydrodilation. Surgical treatment of adhesive capsulitis is indicated for patients with persistent symptoms of the disease and ineffectiveness of conservative treatment. Surgical treatment includes manipulation under anesthesia and / or shoulder capsulotomy (arthroscopic or open). Treatment of adhesive shoulder capsulitis remains an unresolved clinical problem. The existing treatment regimens are not universal and further studies with long-term outcomes are needed to develop more effective treatment modality.

Effects of Nonthrust Joint Mobilization on Clinical Outcomes of Patients With Adhesive Capsulitis of the Shoulder: A Meta-Analysis.

Shoulder adhesive capsulitis is a condition mainly characterized by a decreased range of motion (ROM), with a lifelong prevalence of 2-5%. Intra-articular steroid injection is an important treatment in this disease. It has been suggested that ultrasound-guided (US-guided) intra-articular injections are more accurate and effective than blind injections. This randomized clinical trial was designed to compare efficacy and accuracy of US-guided injections versus blind injections of steroid in the glenohumeral joint. Forty-one patients diagnosed with shoulder adhesive capsulitis were included. Patients randomly underwent intra-articular injection either blind or under guidance of ultrasound by a specialist. Immediately after injection, radiograms were obtained to assess the accuracy of injection. Demographic characteristics, their functional status, the severity of pain, and the ROM were gathered and compared between the two groups. Twenty patients in the US-guided group and 21 in the blind group finished the 4-week period of the study. Improvements in pain, ROM, and functional score after 1 and 4weeks were more prominent in the US-guided group, but the differences were not statistically significant, except for the changes in extension where the improvements were significantly higher in the US-guided group (p=0.01). The accuracy of injections was also higher in the US-guided group (90% vs. 76.19%), but the differences were not found to be significant (p=0.24). US-guided injections can be more accurate and yield better improvements in pain, ROM, and function of the patients, but they cost more and are time-consuming.

Background: Corticosteroid injection has a wide range of success in adhesive capsulitis but the reason for this has not yet been explained. We hypothesized that this difference might be due to the distribution of the corticosteroids injected into the joint cavity because particulate steroid deposits in the capsule and will not be moved over time by shoulder motion. Objectives: The purpose of this study is to determine whether the therapeutic efficacy of particulate corticosteroid injection into the glenohumeral joint differs according to the dispersion pattern. Study Design: Prospective evaluation. Setting: Outpatient clinics at a tertiary university hospital Methods: Seventy-two patients diagnosed as having adhesive capsulitis received a corticosteroid injection at the glenohumeral joint. The posterior capsule and the subscapular bursa were selected as dispersion sites and the dispersion of contrast dye was expressed as a ratio (%). Two weeks and 3 months after the injection clinical improvement (“not improved,” “slightly improved,” “much improved”), numeric rating scale (NRS), and passive range of motions (PROM) were evaluated. The dispersion of the contrast dye was compared according to the clinical improvements by an analysis of variance test. Pearson correlation test was done to find the relationship between PROM and the dispersion and between change of NRS and the dispersion. Results: The distribution in the subscapular area was 30.0% in the “much improved” group, 22.0% in the “slightly improved” group, and 37.1% in the “no improvement” group which was not significantly different (P = 0.179). Correlations between changes of NRS and the dye distribution were not statistically significant (P = 0.429 at 2 weeks and P = 0.629 at 3 months). The change of passive external rotation 3 months after the injection was significantly correlated with the dye distribution (P = 0.035). Limitations: Because of diverse pathologic findings in adhesive capsulitis, further studies will be needed to address the effect of the dye distribution on the pain improvement according to pathologic findings revealed by magnetic resonance imaging (MRI). Conclusion: External rotation of the shoulder in adhesive capsulitis has greater improvement as the corticosteroid solutions injected into the glenohumeral joint are increasingly dispersed to the subscapularis area. However, this does not affect the pain improvement after the injection. Key words: Adhesive capsulitis, dispersion, contrast dye, subscapularis, glenohumeral joint, corticosteroid, range of motion, numeric rating scale

Background An inflammatory condition leading to stiffness and pain in the shoulder joint, adhesive capsulitis is associated with conditions such as diabetes mellitus, cervical spondylosis, thyroid dysfunction, autoimmune rheumatic diseases, and shoulder injury due to trauma, fracture, rotator cuff tear, surgery, or immobilization. Adhesive capsulitis may affect a notable proportion of the diabetic population. There are numerous studies that show that patients with type 2 diabetes mellitus are not only at higher risk of developing adhesive capsulitis but also suffer poor outcomes despite treatment, especially in patients with long-standing diabetes mellitus. Furthermore, there is significant variation in data regarding the prevalence of adhesive capsulitis in Pakistani patients with type 2 diabetes mellitus. Objective To determine the prevalence of adhesive capsulitis among patients with type 2 diabetes mellitus presenting to a tertiary care hospital in Bahawalpur, Pakistan. Methods The present observational cross-sectional study was carried out at the Department of Medicine, Bahawal Victoria Hospital, Quaid-e-Azam Medical College, Bahawalpur, Pakistan, from February 2024 to August 2024. Type 2 diabetes mellitus was labeled by HbA1c of more than 7.0%, or two random blood glucose levels of 200 mg/dL or more, or an existing diagnosis of diabetes mellitus, and/or use of anti-hyperglycemic therapy. Adhesive capsulitis was diagnosed clinically on the basis of history (gradual onset shoulder pain with limitation of movements) and examination (reduction in active and passive range of motion (ROM) of the shoulder, especially abduction, internal rotation, and external rotation) in the absence of significant abnormalities on shoulder X-ray. After ethical approval and obtaining informed consent, 430 patients with type 2 diabetes mellitus were included in the study using a non-probability consecutive sampling technique. Demographic information, diabetes control, and HbA1c levels were noted, and the patients were assessed for adhesive capsulitis. All the data was recorded and entered into IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, NY, USA), for analysis. Results Having a female preponderance (266, or 61.9%), the mean age of the participants was 54.0 ± 13.1 years. With regard to occupational status, 126 (29.3%) had a sedentary occupation, 45 (10.5%) were unemployed, and 259 (60.2%) had a non-sedentary occupation. The mean diabetes duration was 6.4 ± 5.3 years, and the majority of patients had poor diabetes control (322, or 74.9%). Adhesive capsulitis was present in 61 (14.2%) patients with type 2 diabetes mellitus. On stratification, no significant statistical association of adhesive capsulitis was seen with gender (p-value: 0.075), age (p-value: 0.465), occupation (p-value: 0.056), diabetes duration (p-value: 0.118), or diabetes control (p-value: 0.090). Conclusion Adhesive capsulitis was not an uncommon finding in our study, reported in almost one-fifth of the 430 patients enrolled. We recommend that treating physicians screen diabetic patients for adhesive capsulitis so that proper pain relief, physiotherapy, and rehabilitation may be provided timely and efficiently, thereby reducing morbidity and improving the quality of life for such patients.

Adhesive capsulitis (AC), is one of the disorders commonly encountered in clinical practice which caused great disability in performing daily activities. The cause of AC is unknown, but its pathogenesis involves shoulder joint capsule synovial tissue inflammation that produces pain and the formation of fibrotic tissue. The forming of fibrotic tissue causes the shrinkage of joint space and limitation in the shoulder range of motion (ROM). Many modalities of treatment had been used to treat AC, but there has been no consensus regarding the best treatment. Acupuncture had been used in the treatment of AC and showed good results, especially in reducing pain and improving ROM. This paper showcased the effects of manual acupuncture using the wide rotation stimulation method, a rarely used technique that has never been published before, in the treatment of AC. In this case report, the wide rotation stimulation method showed great results in reducing pain and improving ROM.

Efficacy of ultrasonography-guided intra-articular steroid injection of the shoulder and excercising in patients with adhesive capsulitis: Glenohumeral versus subacromial approaches