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Capsulitis — Clinical Guidelines

Overview

Adhesive capsulitis, commonly known as frozen shoulder, is characterized by shoulder pain, stiffness, and fibrosis of the joint capsule, predominantly affecting individuals aged 40-60 years 1 4.

Diagnosis

Clinical Presentation: Pain, restricted shoulder motion, and gradual progression 4.

Imaging: MRI and ultrasound elastography can assess capsule fibrosis and rotator cuff integrity 7 12 13.

Grading Systems: Novel scoring systems enhance diagnostic accuracy and staging 4.

Differential Diagnosis: Rule out rotator cuff pathology and cervical spine issues 12 13.

Management

First-Line Treatments:

- Physical therapy focusing on range of motion exercises 3. - Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management 3.

Adjunctive Treatments:

- Manipulation under anesthesia (MUA) with caution due to potential complications 5 11. - Arthroscopic capsular release for refractory cases 8 10. - Myofascial trigger point therapy, particularly for subscapularis involvement 6.

Specific Techniques:

- FEAR technique (Forward elevation, Extension, Adduction/abduction, and internal and external Rotation) for MUA 5. - Extended rotator interval release arthroscopically 8.

Special Populations

Elderly: Increased risk and prolonged recovery periods 4.

Comorbidities: Higher incidence post-cervical disc surgery 9.

Key Recommendations

Utilize comprehensive scoring systems for accurate diagnosis and staging of adhesive capsulitis (Evidence: Moderate 4).

Incorporate physical therapy with emphasis on range of motion exercises as a first-line treatment (Evidence: Moderate 3).

Consider arthroscopic interventions for patients refractory to conservative management (Evidence: Weak 8 10).

Exercise caution with manipulation under anesthesia due to potential complications like shoulder dislocation (Evidence: Weak 5 11).

Evaluate and treat myofascial trigger points, especially in the subscapularis, to improve pain and function (Evidence: Expert opinion 6).

References

1 Qi B, Wang Q, Shi S, Wang Q, Jiang W, Wang C et al.. Si-ITGA6-Loaded Liposomes Inhibit Capsule Fibrosis via the FAK/PI3K/Akt Signaling Pathway in Adhesive Capsulitis of Shoulder. International journal of nanomedicine 2025. link 2 Zorgno I, Simeone FJ, Galdamez ME, Chang CY, Huber FA, Torriani M. Decreased rotator cuff muscle cross-sectional areas in subjects with adhesive capsulitis: a study comparing male and female subjects. Skeletal radiology 2024. link 3 Park GY, Kwon DR, Cho HK, Kwon DY. Clinical Impairments and Rotator Cuff Tendon Pathology in Primary and Intrinsic Secondary Adhesive Capsulitis. American journal of physical medicine & rehabilitation 2024. link 4 Vita F, Donati D, Tedeschi R, Miceli M, Spinnato P, Origlio F et al.. A comprehensive scoring system for the diagnosis and staging of adhesive capsulitis: development, application, and implications. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie 2024. link 5 Pharr ZK, Bowman EN, Blickenstaff BE, Hubler AK, Brolin TJ, Throckmorton TW et al.. Frozen Shoulder Manipulation with the FEAR Technique: A Retrospective Case Series with Minimum Two-Year Follow-up. Journal of surgical orthopaedic advances 2022. link 6 Bağcıer F. An overlooked issue in frozen shoulder: Miyofascial trigger point. Agri : Agri (Algoloji) Dernegi'nin Yayin organidir = The journal of the Turkish Society of Algology 2021. link 7 Yun SJ, Jin W, Cho NS, Ryu KN, Yoon YC, Cha JG et al.. Shear-Wave and Strain Ultrasound Elastography of the Supraspinatus and Infraspinatus Tendons in Patients with Idiopathic Adhesive Capsulitis of the Shoulder: A Prospective Case-Control Study. Korean journal of radiology 2019. link 8 Tsai MJ, Ho WP, Chen CH, Leu TH, Chuang TY. Arthroscopic extended rotator interval release for treating refractory adhesive capsulitis. Journal of orthopaedic surgery (Hong Kong) 2017. link 9 Kang JH, Lin HC, Tsai MC, Chung SD. Increased Risk for Adhesive Capsulitis of the Shoulder following Cervical Disc Surgery. Scientific reports 2016. link 10 Karas V, Riboh JC, Garrigues GE. Arthroscopic Management of the Stiff Shoulder. JBJS reviews 2016. link 11 Roubal PJ, Placzek JD. Long-Lever-Arm Manipulation Under Anesthesia With Resultant Traumatic Anterior Shoulder Dislocation. The Journal of orthopaedic and sports physical therapy 2016. link 12 Loeffler BJ, Brown SL, D'Alessandro DF, Fleischli JE, Connor PM. Incidence of False Positive Rotator Cuff Pathology in MRIs of Patients with Adhesive Capsulitis. Orthopedics 2011. link 13 Yoo JC, Ahn JH, Lee YS, Koh KH. Magnetic resonance arthrographic findings of presumed stage-2 adhesive capsulitis: focus on combined rotator cuff pathology. Orthopedics 2009. link

Capsulitis