Adhesive Capsulitis: Prospective Analysis of Efficacy and Financial Impact for Use of Physical Therapy in Treatment

A. Objectives

The purpose of this study is to identify individuals 18 or older who have diagnostic presentation of adhesive capsulitis and randomize them into two arms, distinguished by use of physical therapy and steroid injections compared with steroid injections followed by watchful waiting. This prospective study will be used to determine whether there is a significant impact on patient outcome and whether the additional financial burden is justified. The standard of care calls for initial non-operative therapy consisting of NSAIDs, watchful waiting, and oral and parenteral corticosteroid administration with consideration for operative therapy after 6 months of failed conservative therapy. We would like to enroll patients who are willing to be randomized and postpone operative therapy for a period of up to one year during which we would have scheduled follow up visits at regular intervals. There are no experimental interventions for this study. The use of physical therapy, oral and parenteral corticosteroids, and watchful waiting are offered following the standard of care for adhesive capsulitis.

B. Background Adhesive capsulitis, also known as "frozen shoulder" is a common orthopedic condition affecting 2-5% of the general population13. As defined by the American Academy of Orthopedic Surgeons, it is a self-limiting condition resulting from any inflammatory process about the shoulder in which capsular scar tissue is produced, resulting in pain and limited range of motion.

The majority of shoulder function comes from the interactions of the glenohumeral ligament complex, the rotator cuff complex, and the articulating bones. The superior glenohumeral ligament is important in stabilization of the glenohumeral joint in adduction and external rotation. The middle glenohumeral ligament is an important stabilizing structure in the positions of adduction and external rotation and abduction up to 45° in external rotation. The resistance, and therefore tension, of the inferior glenohumeral ligament, which is negligible in positions of neutral adduction and adduction in external rotation, increases in value for angles between 45° and 90°, indicating the important stabilizing function of this ligament in those positions. The rotator cuff is comprised of the tendons of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles1,10.

In this disease state, there is a capsular pattern of shoulder dysfunction which is characterized by slight limitation of medial rotation, moderate limitation of passive abduction, and most importantly, severe limitation of lateral rotation. The finding of lateral rotation limitation or capsular pattern of limitation can be diagnostic in the assessment of AC.