THE CLINICAL SYNDROME

• There are a number of conditions that can manifest in the shoulder joint that can lead to damage or inflammation of the joint cartilage, as well as the tendons, ligaments, and soft tissues surrounding the joint.

• Even though the majority of these conditions can result in discomfort and a reduction in functional ability, a positive outcome is anticipated when they are effectively managed.

• However, in some patients, an increase in pain and inflammation leads to the development of edema and stiffness of the soft and connective tissues of the shoulder.

• This, in turn, results in the formation of fibrous adhesions, which severely restrict the range of motion of the joint.

• If this condition is left untreated, the patient may eventually develop a frozen shoulder, which can cause significant pain and functional disability.

• If there is no history of prior trauma in the patient's medical history, this condition is more likely to manifest itself in females and patients older than 40 years of age.

• There are two broad categories that can be used to classify the diseases that put a patient at risk for developing adhesive capsulitis: (1) diseases that occur within the shoulder and proximal upper extremity (such as rotator cuff tendinopathy, subdeltoid bursitis, and biceps tendon tendinopathy), and (2) diseases that occur outside of the shoulder region (such as stroke, diabetes, myocardial infarction, tuberculosis, Parkinson'

• If adhesive capsulitis is not promptly diagnosed and treated, the patient will almost always have a poor clinical outcome.

• This is true even if the underlying cause of adhesive capsulitis is known and treated.

SIGNS AND SYMPTOMS

• The majority of patients who present to their doctor complaining of shoulder pain due to adhesive capsulitis report that the pain is localized to the area around the shoulder and upper arm.

• The pain is made significantly worse by activity, whereas resting and applying heat offers some relief.

• The pain is consistent and has been described as an aching sensation; it may prevent one from sleeping.

• On physical examination, crepitus may be present in some patients, and some patients report that using the joint causes them to experience a grating or popping sensation.

• In addition to experiencing pain, patients who suffer from adhesive capsulitis of the shoulder joint frequently experience a gradual reduction in functional ability.

• This is caused by a decrease in shoulder range of motion, which makes it difficult to perform even the most basic of daily activities, such as reaching overhead, combing one's hair, or fastening a brassiere.

• Muscle atrophy and the development of a frozen shoulder are both potential outcomes of prolonged periods of inactivity.

• Sleep disturbances are quite common in patients who are afflicted with adhesive capsulitis.

• These sleep disturbances may further aggravate the patient's existing pain.

TESTING

• For the purpose of eliminating other potential sources of shoulder pain, plain radiographs are recommended for all patients in whom adhesive capsulitis is suspected to be the underlying condition.

• The clinical presentation of the patient may suggest the need for additional testing, which may include an evaluation of the patient's complete blood count, erythrocyte sedimentation rate, and antinuclear antibody levels.

• Indications for magnetic resonance imaging of the shoulder include the detection of abnormalities of the shoulder that can be treated (such as tears in the rotator cuff), as well as the determination of the severity of adhesive capsulitis.

• If there is a possibility of metastatic disease or a primary tumor involving the shoulder, then radionuclide bone scanning is something that should be done.

• Shoulder pain can be caused by a variety of conditions that are not local to the shoulder region, such as pericarditis, hypothyroidism, and reflex sympathetic dystrophy.

• Extensive diagnostic testing to rule out these diseases is required in order to have any hope of successfully diagnosing and treating the condition.

DIFFERENTIAL DIAGNOSIS

• However, rheumatoid arthritis, posttraumatic arthritis, and rotator cuff arthropathy are also common causes of shoulder pain.

• Shoulder pain is most commonly caused by osteoarthritis of the joint, which is the most common form of arthritis that results in shoulder pain.

• Shoulder pain that is caused by arthritis can also be caused by collagen vascular diseases, infections, villonodular synovitis, and Lyme disease, although these are less common causes.

• Acute infectious arthritis is typically accompanied by significant systemic symptoms, such as fever and malaise, and it should be easy to recognize; the condition is diagnosed through culture and treated with antibiotics, as opposed to injection therapy.

• Shoulder pain that is caused by collagen vascular disease responds exceptionally well to the intraarticular injection technique that is described in this article.

• However, collagen vascular diseases typically manifest as polyarthropathy rather than as monarthropathy that is limited to the shoulder joint.

TREATMENT

• The initial treatment for the pain and functional disability associated with adhesive capsulitis of the shoulder consists of a combination of physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors.

• Both of these types of medications are anti-inflammatory medications.

• The application of heat and cold to the affected area locally, as well as the utilization of ultrasound therapy, may also be beneficial.

• Patients who do not respond to these treatment modalities may benefit from an intraarticular injection of a local anesthetic and steroid as the next logical step in the treatment process.

• After receiving an injection for shoulder pain, the patient should wait several days before beginning physical therapy treatments.

• These treatments should include gentle range-of-motion exercises, local heat therapy, and ultrasound therapy.

• Acupuncture and transcutaneous electrical nerve stimulation (TENS) are two other potential alternative treatment options.

• When traditional treatments have failed, it's possible that extracorporeal shock wave therapy could be beneficial.

• Exercises that are too strenuous for the patient should be avoided because doing so will make their symptoms even worse.

• Stellate ganglion blocks should be used to treat any underlying reflex sympathetic dystrophy of the affected extremity as soon as possible in the course of the disease.

COMPLICATIONS AND PITFALLS

• If the clinically relevant anatomy is carefully considered before administering the injection, this method does not pose a safety risk.

• In order to prevent infection, sterile technique must be utilized, and universal precautions must be taken in order to lessen the likelihood that the operator will be put in harm's way.

• If pressure is applied to the injection site immediately after the injection, this can help reduce the risk of complications such as ecchymosis and hematoma formation.

• Infection is the most significant risk associated with intraarticular injections into the shoulder joint; however, if proper aseptic procedure is followed, the risk of infection should be extremely low.

• Patients should be warned about the possibility of experiencing a temporary increase in pain after receiving an intraarticular injection into the shoulder joint, as this affects approximately thirty percent of patients.