Primarily an inflammatory reaction in the capsule and synovium that subsequently leads to the formation of adhesions, specifically in the axillary fold and in the attachment of the capsule at the anatomic neck
Aetiology
Not definitely established, but thought dependency of the arm over an extended period of time can lead to the development of capsular contracture
Associations
- Shoulder Hand Syndrome (RSD Type III)
- May follow voluntary immobilisation, caused by
- Acute or chronic tendinitis
- Coronary artery disease
- Mastectomy or other operations about the chest and shoulder that require prolonged immobilisation
- IDDM
- Hyperlipidemia
- Parkinsonism
- Thyroid disorders
Incidence
- Usually women
- The non dominant arm is usually involved
- Sedentary occupations
Clinically
- Patient usually aged 40 - 60 years
- May give a history of trauma, but this is usually trivial
- Gradual onset of stiffness may precede pain, often referred to the insertion of the deltoid
- Pain gradually increases in intensity and may prevent sleeping on the affected side
- Rarely a localised tender spot is evident
- Restriction of motion both actively and passively, mainly in the planes of abduction, internal and external rotation
- After several months, pain gradually subsides, but stiffness develops and persists for some time, following resolution of pain
- 3 phases :
- Phase 1: Increasing pain and increasing stiffness (Inflammatory/Active phase)
- Phase 2: Decreasing pain with persistent stiffness (Freeze phase)
- Phase 3: Painless return of movement (Thaw phase)
- Usually nothing to see, except perhaps slight wasting
- Movements are grossly restricted in all directions and in the mildest cases this restriction may be only slight
X-Rays
- Bone density is usually decreased in the region of the greater tuberosity
- Arthrography: contracted joint is the most reliable diagnostic investigation
- Normal shoulder accepts 20 ml of fluid without difficulty, but in this condition usually less than 10 ml
- MRI shows loss of axillary recess
Pathology
- Probably begins in the same way as chronic tendinitis, but spreads to involve the entire tendinous cuff and leads to thick, vascular and painful capsule
- The capsule and synovium may be obliterated by adhesions and may be the result of an autoimmune response to the products of local tissue breakdown
Stages
- Stage I: Pre-adhesive stage, where there is minimal or no limitation of movement and there is a fibrinous synovial inflammatory reaction evident only on arthroscopy
- Stage II: Acute adhesive synovitis, with proliferative synovitis and early adhesion formation evident on arthrography
- Stage III: Maturation of adhesions with less synovitis and loss of the axillary fold
- Stage IV: Chronic stage, adhesions are mature and markedly restrictive
Differential Diagnosis
Must be differentiated from a stiff and painful shoulder, which includes any condition around the shoulder that is painful and causes apparent limitation of motion (in these cases there is no capsular contracture)
Such conditions include :
- Calcific tendinitis
- Non calcific tendinitis
- Bicipital tenosynovitis
- Arthrosis of gleno-humeral or acromio-clavicular joint
- Tears of the rotator cuff
- Hemi-arthrosis
- Sprain of the rotator cuff
- Synovitis
These patients usually have a more acute onset of pain and a history of repetitive overhead activity or trauma may be evident. There is no sense of mechanical restriction at the limits of passive motion (movement is limited by pain)
Treatment
- Aim to relieve the pain and prevent further stiffening, while recovery is awaited
- Reassure the patient that recovery is certain
- Local physiotherapy modalities, esp. moist heat and stretching
- Vigorous or forceful exercises are contraindicated
- Injection of local anaesthetics and steroids sometimes helps
- Once over inflammatory phase an MUA and injection may hasten recovery
- MUA : First flex the arm, then rotate the extremity externally, then abduct the arm, and once the arm is fully above the patients head go to internal rotation with the arm at 90o .Institute physiotherapy immediately post operatively to maintain the ROM achieved
- MUA is contraindicated in severe osteopenia or if there is a history of fracture or dislocation
- Arthroscopy has little place in the treatment of this condition
- Indicated only after 3-6 month of unsuccessful conservative therapy
- Can be used for lysis of adhesions, release of rotator interval and/or posterior capsule
Prognosis
Generally thought to be a self limiting condition that will resolve within a year without any particular therapeutic intervention
