Adhesive capsulitis: A sticky issue

8/9/2019 Adhesive capsulitis: A sticky issue

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Adhesive Capsulitis: A Sticky IssueLORJ B. SIEGEL. M.D., NOR MA N |. COH EN , M.D., and ERIC P. GALL, M.D.Finch University of Health Sciences/Chicago Medical School, North Chicago, IllinoisThe shoulder is a very complex joint that is crucial to many activities of daily living.Decreased shoulder mobility is a serious clinical finding. A global decrease in shoulderrange of motion is called adhesive capsulitis, referring to the actual adherence of theshoulder capsule to the humeral head. Adhesive capsulitis is a syndrome defined as idio-pathic restriction of shoulder movement that is usually painful at onset. Secondary causesinclude alteration of the supporting structures of and around the shoulder, and autoim-mu ne, endocrine or o ther systemic diseases. The three define d stages of this cond ition arethe painful stage, the adhesive stage and the recovery stage. Although recovery is usuallyspontaneous, treatment with intra-articular corticosteroids and gentle but persistentphysical therapy may provide a better outcome, resulting in tittle functional compromise.

O A patient informa-tion handout on adhe-sive capsulitis. writtenby the authors of thisarticle, is provided onpage 1851.

T he shoulder is a complex ana-tomic structure that allowsmovement in many planes.Physicians and patients alikedon't often think about theimportance of the shoulder joint until its func-tion becomes compromised. It then becomesobvious how crucial it is for many essentialactivities. The expression "If you don't use it,you lose it" applies perfectly to diseases of theshoulder because any voluntary or involuntaryguarding of the shoulder may result in loss ofmobility. The term "frozen shou lder" has beenloosely applied to conditions when tbe shoul-der is working at less than its optimal range.Because the shoulder joint is so com plex, it isimportant to determine the precise cause forloss of shoulder mobility. It is paramount thatphysicians use proper term inology so that theycan com mu nicate effectively and treat patientsappropriately.Definition of Terms

Many terms are used to describe limitationof shoulder mov emen t, and all of them implya stiff shoulder with decreased range ofmotion (Table 1). These terms are attempts todescribe the probable underlying pathophys-iologic process (i.e., bursal or capsular originsof inflamm ation). They were used to describeconditions that are difficult to understandand explain and, although of historic interest,they are confusing and are best discarded.The term "frozen shoulder" encompasses

many of the concepts of the terms in Table 1but it too is confusing and not always accu-rate. The correct term for true global decreasein shoulder range of motion is adhesive cap-sulitis, related to the surgical findings ofactual adherence of the capsule to thehumeral head.' ' 'Adhesive capsulitis is a syndrome definedin its purest sense as idiopathic painfulrestriction of shoulder mo vement that resultsin global restriction of the glenohumeraljoint. It is not associated with a specific un-derlying condition. It has also been describedas a condition of "unknown etiology charac-terized by gradually progressive, painfurestriction of all joint motion . .. with spon-taneous restoration of partial or completemotion over m on ths to years."' To avoid con-fusion, the term "adhesive capsulitis" shouldbe used to reter to the primary idiopathiccondition and the term "secondary adhesive

capsulitis" should be applied to the con ditionthat is associated with, or results from, otherpatholog ic states. Each case must be evaluated

TABLE 1Terms Used to DescribeLimited Shoulder MobilityFrozen shoulderAdhesive capsulitisPericapsulitis

PeriarthritisAdherent bursitisObliterative bursitis


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to determine if the restriction is idiopathic(pr imary) or the result of an underlying sys-temic illness o r anatomic process (secon-dary) . Either condition causes pain an ddecreased shoulder mobility.

Subacromial or subdeltoid bursitisBicipital tendinitis(insertion of the longhead of the bicepsmuscle in thebicipital groove)

Acromioclavicularjoint arthritis

Rotator cuff tendinitis

FIGURE 1. Anatom y o f shoulder in diagnosis of shoulder pain.

FIGURE 2. Note the marked limitation of active abduction of the leftshoulder in a patient with adhesive capsulitis.

Differential DiagnosisComplaints of shoulder pain o r m o v em en t

p r o b lem s a re difficult to evaluate . Manyshoulder conditions have similar symptoms,causes, precipitating factors an d treatments.Multiple pathologic lesions may b e present ina single joint."* In assessing a patient's shoulderpain, th e physician must distinguish betweentrue glenohumeral joint problems and extra-articular derangements. Active range ofmotion will most likely be limited and painfulin both cases, b ut decreased passive range ofmotion, which is often painful as well, mostlikely indicates true joint pathology.

If the patient is able to relax and the exam-iner ca n elicit full passive range of motion , th eetiology of the pain is most likely to be extra-articular. Prolonged soft tissue problems, how-ever, may even tually lead to decreased shoulderrange of motion because of the patient's co n -stant guarding of the shoulder. It is imperativeto determine th e precise source of shoulderpain (Figure 1) so that a program of physicaltherapy can be initiated to prevent compro-mise of shoulder movement (Figure 2) . Extra-articular pain m ay result from strain o rinflammation of muscles, tendons or bursae.

The differential diagnosis of shoulder prob-lems is protean, b ut physicians should be ableto readily recall some of the m o r e co m m o ncauses of shoulder pain an d decreased range ofmotion. Bicipital tendinitis m ay affect activeshoulder movement and is diagnosed by elicit-ing tenderness while pressing on the long headbicipital tendon in the bicipital groove. T hebicipital tendon passes through th e gleno-humeral joint .

Pain o n extension may b e elicited by testingfor Yergason's .sign (Figure 3). T he patient isasked to resist supination of the forearmwhile the physician presses on the bicipitaltendon in the groove on the humerus. Painwith resisted forward flexion (Speed's test),may also b e present (Figure 4).

Tendinitis of the rotator cuff is the mostcommon cause of shoulder pain and sec-


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FIGURE 3. Yergason's sign. The patient resistssupination of the forearm while th e physicianpresses on the bicipjtal tendon.FIGURE 4. Speed's test. The patient is asked toflex th e forearm while th e physician providesresistance.

ondary decreased shoulder mobil i ty thatmanifests with pain on passive and activeabduction.^'' Pain is usually gre ater w ith inter -nal rotation of the shoulder than with externalrotation. The key finding is pain in the rotatorcuff on active abduction, especially at 60 to100 degrees of abduction. Ultimately, theremay be impingement and a loss of mobility.Tenderness may be elicited anteriorly over tbehum eral bead when the arm is extended. Cal-cific tendinitis may also lead to impingement.

The subacromial and subdeltoid bursae arecontiguous in most persons. Subacromialbursitis manifests with pain when the patientlies on bis or her shoulder, or with tendernesson palpation of the space on the lateral aspectof the shoulder just inferior to the acromionalong tbe deltoid. Subacromiat bursitis mayalso be a reactive phenomenon in a patientwith a rotator cuff injury. Acromioclavicularjoint problems, commonly including osteo-arthritis, may also result in decreased passivejoint range of motion and local tenderness.

True shoulder pain presents with tendernesson anterior or posterior palpation. Decreasedjoint motion is compensated for by an increasein scapulothoracic motion during flexion andabduction. Increased scapulothoracic motionstresses other structures around the shoulderand may result in more global pain syndromes,guarding and decreased range of motion.

The evaluation of shoulder instability isimportant in patients with shoulder pain.Symptomatic subluxation may cl inical lymim ic an acute rotator cuff injury o r bicipitaltendinitis. A high index of suspicion and adetailed physical examination combining theassessment of laxity in all directions witbstress tests can belp the physician determinethe underlying cause of pain. Correction ofany muscle imbalance i s paramount topreservation of mobility and function. Mus-cles around tbe neck and shoulder girdleshould be palpated for tenderness or triggerpoints to assess for fibromyalgia, myofascialpain syndromes and cervical osteoarthritis.

The correct diagnosis in a patient witbrestricted shoulder movement on pbysicalexamination and any of the previously men-tioned findings, sucb as bursitis or ten dinitis, issecondary adhesive capsulitis. Tbe underlyingcondition is docum ented as the primary p rob-lem leading to secondary adhesive capsulitis.Adhesive CapsulitisFEATURES, PRESENTATION AN D NATURAL HISTORY

Primary idiopathic adhesive capsulitis isdifficult to defme, diagnose and manage. Thiscondition affects 2 to 3 percent of tbe popula-tion. It tends to occur in patients older tban 40years of age and most commonly in patientsin their 50s and in women. Fifteen percent of


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Adh esive capsulitis has three defined stage s: the painfulstage, the adhesive stage and the recovery stage.

patients develop bilateral disease. Adhesivecapsulitis has been reported in children.^The natural history of adhesive capsulitisand its dinicai course is divided into threestages: the painful stage, the adhesive stageand the recovery stage (Tnble 2) . The painfiilstage involves gradually increasing pain andstiffness and lasts between three and eightmonths. Muscle spasms in the trapezius alsocommonly occur during this phase. A historyof a minor strain or injury before onset may

be noted; however, it is unclear whether theinitial strain is an independent phenomenonor an early awareness of the pain associatedwith the onset of adhesive capsulitis.Comm only, patients note a decreased abil-ity to reach behind the back when fastening agarment or removing a wallet from a backtrouser pocket. The initial discomfort isdescribed by many patients as a generalizedshoulder ache w ith difficulty pinpo inting theexact location of the discomfort. The painmay radiate both proximally and distally, isaggravated by movement and alleviated withrest. Sleep may be interrupted if the patientrolls on the involved shoulder.This cond ition progresses to on e of severepain accompanied by stiffness and decreasedrange of motion. The stiffening increases tothe point where the natural arm swing thataccompanies normal gait is lost." The patienttries to compensate for this loss by usingother muscles and increasing scapular rota-tion to accomplish various activities. This

places additional strain on the other musclegroups, leaving them overworked and tender.The physical examination during thepainful stage of adhesive capsulitis m ay revealmuscle spasm and diffuse tenderness aboutthe glenohumeral joint and the deltoid mus-

cle. An area of pinpoint tenderness is seldomfound. With disease progression and in long-standing cases, disuse atrophy of the sho uldergirdle may result. Passive and active range ofmotion in all planes of shoulder movementare lost (Figure 5 ). This global loss of motionis the primary factor distinguishing adhesive

capsulitis from many of the conditions asso-ciated with secondary adhesive capsulitis.The second stage, the adhesive stage,involves increasing stiffness with diminishingpain. Pain decreases at night, and discomfortoccurs only at the extremes of motion, al-though movement is dramatically decreased.This stage lasts four to six m onth s.The final stage, called the recovery stage,lasts from one to three m onths and is charac-terized by minimal pain but severe restriction

of mo vem ent. This latter stage is self-limiting,with a gradual and spontaneous increase inrange of motion. Complete recovery, how-ever, is infrequent. Tbe external rotationrange of motion improves first, followed byabduction and internal rotation. Short recov-ery periods may have associated bou ts of painbefore each phase of improv emen t. Althoughapproximately 7 to 15 percent of patients per-manently lose their full range of motion, onlya few have a true functional disability.**"*PATHOLOGY

The pathophysiology of primary and sec-ondary adhesive capsulitis rem ains elusive. It isbelieved that in patients with diabetes, associ-ated microvascular disease causes abnormal

TABLE 2The Three Stages of Adhesive CapsulitisPainful stagePdin with movementGeneralized ache that is difficult to pinpointMuscle spasmIncreasing pain at night and at restAdhesive stageLess painIncreasing stiffness and restnction of movementDecreasing pain at night and at restDiscomfort felt at extreme ranges of movementRecovery stageDecreased painMarked restriaion w ith slow, gradual increase inrange of motionRecovery is spontaneous but frequently incomplete


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Adhes ive C apsulitis

FIGURE 5. Decreased passive extension in apatient with adhesive capsulitis.collagen repair, which predisposes them toadhesive capsulitis. Occasionally, fibrousstrands are seen traversing the joint space (Fig-ure 6). Patients with diabetes often presentwith fibros is elsewhere (i.e., Dupuytren's con-tracture). Irauma, the associated transientinflammatory state with granulation tissue,and eventual fibrous adhesions and thickeningof the capsule may cause adhesive cap sulitis.'"

Immobilisation is an intriguing possibleetiologic factor for adhesive capulitis in pa-tients with stroke or postmyocardial infarc-tion; however, prolonged casting studies havenot supported this theory." Neuropathicmechanisms, including suprascapular nervecompression, have been considered, but noneaccoun ts for mo.st cases of adhesive capsulitis.Although strong evidence suggests an associa-tion among these neuropathic and vascularconditions and adhesive capsulitis, no p atho-physiologic mechanisms are convincing.

Theories regarding autoimmune reactionto tendon degeneration have led to immuno-

logic investigations. Although random andinconsistent, the inflammatory indexes mea-sured (e.g., erythrocyte sedimentation rate)were partially supported because they wereslightly elevated and improved as the diseaseimproved." Synovial fluid offers no clues tothe etiology of adhesive capsulitis. Biopsies ofthe synovial lining have revealed increasedfibroblasts and vascular dilatation, but few orno perivascular inflammatory cells.EVALUATION

The diagnosis of adhesive capsulitis is pri-marily clinical. In general, the scapular rota-tion occurs at 60 degrees with active abduc-tion of the shoulder. In an unaffected perso n,the sh oulder can be passively abducted to 90degrees even w hen the physician holds thescapula. Inability to achieve the 90-degreearcwith scapular stabilization is the clue to thediagnosis in both primary and secondaryadhesive capsulitis. It is important to assurethat the scapula is secured when assessingpassive range of mo tion (Figure 7) .

Radiographs are important in assessingrestricted range of mo tion in the diagnosis ofsecondary adhesive capsulitis. Osteo arthritis,fracture, avascular necrosis, crystalline ar-thropathy, calcific tendinitis and neoplasmmay be detected on plain radiograph s. Radio-graphs of pa tients with early adhesive capsu li-

LFIGURE 6. In a patient with diabetes and adhesive capsutitis, MRI of the shoulder (left) reveals afibrous band traversing the glenohum eral join t space (arrow).


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FIGURE 1. Markedly decreased passive abduc tion is shown in a patien twith adhesive capsulitis, with the scapula stabilized to prevent earlyscapulothoracic movement.

tis are no rmal. Later changes sometimes showosteopenia, q'st-like changes in the humeralhead and joint-space narrowing . A chest radio -graph may be useful in establishing the diag-nosis of tuberculosis or malignancy-associ-ated adhesive capsulitis.

A rthrography, although invasive, is useful todocument decreased joint volume. The unaf-fected shoulder will accommodate 20 to 30mL of co ntrast m aterial, whereas the shou lderwith adhesive capsulitis will only be able tohold 5 to 10 mL. Arthrograms may reveal anirregularity of the capsular insertion at theanatomic humeral neck and a decreased axil-lary fold. From 10 to 30 percent of patients arefound to have a dem onstrable rotator cuff tearat arthrography, yet a significant number also

The AuthorsLORI 8. SIEGEL. M.D ., is chief o f the Division of R heum atolog y at Finch University ofHealth Sciences/Chicago Medical School, No rth Chica go, II I . She is director of under-gradu ate edu cation in the Departm ent of Medicine, Dr. Siegel received her m edicaldegree f rom the Medica l Col lege of Wisconsin, M i lwaukee, and completed a resi-dency in in temal medic ine and a fe l lowship in rheumato logy at Georgetown Univer-sity Hospital, Washington, D.C.NORM AN J. COHEN, M .D,, IS an orthoped ic surgeon in pr ivate practice and clinicalassistant professor in the D epartm ent of Surgery at Finch University of Health Sci-ences /Chicag o Me dical S chool. He is also on staff at Highland Park (III,) Hos pital. Dr,Cohen received a medical degree from A lbert Einstein College of Medicine of YeshivaUniversity, Bronx, N.Y., and com pleted training in general surgery and or lhop edicsurgery at the University of I ll inois College of Med icine, Chicago.ERIC P GALL, M.D,, is professor and chairma n of the Depa rtment of M edicine a t FinchUniversity o f Health Sciences/Chicago Me dical Sc hool, Dr, Gall is also professor ofimmunology and microbiology at the same institut ion. He received his medical degreefrom the University of Pennsylvania School of Medicine, Philadelphia, where he alsocom pleted a residency in internal medicine and a fellowship in rheu ma tologyAddress correspondence to Lor i B . Siegel,M.D., Division of Rheumatology, Finch Uni-versity of Health Sciences/Chicago Medical School, 3333 Green Bay Rd., N orthChicago, IL 60064. Reprints are not available from the authors.

have normal findings. Arthrography shouldbe reserved for use in patients whose diagno-sis remains uncertain following physicalexamination and radiography.Arthroscopy may have a limited role in thediagnosis of other diseases that mimic adhe-sive capsulitis, but it does not aid in the diag-nosis of adhesive capsulitis itself and is notused frequently.'- The usefulness of magneticresonance imaging (MR!) in the diagnosis ofadhesive capsulitis has also been evaluated.''

Studies revealed that some changes seen onMRI are specific and sensitive for adhesive cap-sulitis; however, the decrease in joint fluid isnot appreciated. MRI may become a useful,noninvasive way to document capsular thick-ening, but further studies are needed. I n mostcases, the diagnosis of adhesive capsulitis isclinical; however, if any imaging is necessary,arthrography remains tlie procedure of choice.If there are no underlying illnesses, laboratoryinvestigations will be unremarkable.Other Causes ofSecondary Adhesive Capsul i t is

Some systemic diseases are known to beassociated with adhesive capsulitis (Table 3)and should be considered in patients withrestricted shoulder movement. Trauma, avas-cuiar necrosis and osteoarthritis may predis-pose a patient to secondary adhesive capsuli-tis. Systemic diseases such as diabetes,hyperth}Toidism and rheumatoid arthritis arealso associated with secondary adhesive cap-sulitis and must be considered in a patientwith limited range of motion of the shoul-jgj.i-1,15 Patients often have referred shoulderpain from the heart, neck, diaphragm, liver orspleen. It is unclear why p atients with a historyof myocardial infarctions, cerebrovascularaccidents and chronic pulmonary diseases,such as tuberculosis and p ulm ona ry cancer,are also predisposed to adhesive capsulitis.Patients with reflex sympathetic dystrophy(related to some of these events) may haverestricted range of motion of the shoulderthat becom es perma nent in the later stages of


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Inability to passively abduct the shoulder in a 90-degree arcwith scapu iar stabilization indicates primary or second arycapsulitis.

disease. Some patients m ay also develop reflexsympathetic dystrophy as a result of p rimaryor secondary adhesive capsulitis.Management

Although studies comparing various treat-ment modalities for adhesive capsulitis revealthat no specific treatment method has anylong-term advantage, early and accurate diag-nosis is imperative.'*' In pa tients with adhesivecapsulitis, the goal of treatment is pain reduc-tion and preservation of shoulder mobility.The firststep is preventing secondary adhesivecapsulitis by definitively addressing underly-ing causes. Avoiding prolonged immobiliza-tion in patients who may be predisposed toadhesive capsulitis is crucial.

Treatment of a shoulder injury of any etiol-ogy requires early range of m otion therapy toreduce muscle spasm while maintaining fullrange of motion . Heat, cold and other m odal-ities that relax the muscles may help preserverange of motion. Adequate analgesia is neces-sary for successful treatment in this phase.Vigorous and forceful exercises are con-traindicated because of the pain associatedwith the ru pture of adhesions. Also, the morepainful treatment regimens have been foundto be associated with a higher level of non-compliance. Constant encouragement is nec-essary for patients with adhesive capsulitis,since resolution may be slow. Graduallyincreasing the range of motion of the shoul-der will decrease the pain associated with thedisease. Physical therapy done at home,including Codman exercises, "climbing thewall" or placing things up higher to encour-age reaching, is cost effective but requires along rehabilitative p roce ss.''

Nonsteroidal anti-inffammatory drugs(NSAIDs) help to relieve pain and inflamma-tion. Analgesics are indicated when NSAIDsare contraindicated. Muscle relaxants arehelpful in the early stages of the disease whenspasm is predominant. Low-dose antidepres-sant medications (e.g., 10 mg of amitriptyline[Elavil] taken at night) may help to avoid a

cycle of sleep disturbance leading to a chronicpain syndrome and fibromyalgia.*Intra-articular corticosteroid injections areused in affected patients to relieve pain andpermit a more vigorous physical therapy ro u-tine. The injection site is located 1 cm distaland 1 cm lateral to the coracoid process'^

(Figure 8). Full external rotation of thehumerus with the elbow held in a relaxedposition at the patient's side helps open up thespace, which is difficult to en ter if contractedby adhesive capsuHtis.'"^ Th e usual dosage is 15to 40 mg of triamcinolone acetonide (Kena-log) or another depot steroid with 1 mL of 1percent lidocaine. Although intra-articularcorticosteroids are frequently used, no long-term benefits fi-om this therapy (i.e., shortertime to fijll recovery) have been proved. Someclinicians advocate simultaneous intra-articu-lar and bursal injections for pain relief beforebeginning physical therapy. Oral corticos-teroids are not helpful.

Severe adhesive capsulitis diagnosed in thelater stages is more difficult to manage. Theabove treatmen ts, useful on occasion, are notalways successful. Surgical interventionshould be considered when physical therapyand injections fail (no improvement afterthree months of therapy). Manipulationunder anesthesia to break up the adhesions isreserved for use in the adhesive stage. Duringthis procedure, the joint capsule and sub-scapular muscles are ruptured, and aggressiverehabilitation is employed to restore andmaintain range of motion of the shoulder.

TABLE 3Diseases and Conditions Associatedwith Secondary Adhesive CapsulitisDiabetes me!litusThyroid illnessTraumaRheumatoid arthritisLung cancer

Pulmonary tuberculosisChronic lung diseaseMyocardial infarctionCerebrovascularaccidents/hemiplegia

SclerodermaPostmastectomyCervical radiculitis


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Adhesive Capsulitis

Patients undergoing manipulation mayreceive an intra-articular corticosteroid injec-tion after the procedure and begin physicaltherapy the day of the procedure. Icing isoften helpful.Another option is the administration of aninterscalene block before the manipulation;this renders the patient painfreeand allows forthe immediate start of physical therapy. Risksassociated with manipulation under anesthe-sia include humeral fracture, dislocation and

rotator cuff rupture. Contraindications tomanipulation include severe osteopenia, a his-tory of fracture or dislocation, or recurrencefollowing adequate manipulation.'^ Forpatients with loss of motion refractory toclosed manipulation, arthroscopic capsularrelease has been shown to improve motionwith minimal operative morbidity.^" In thisstudy, most patients had a marked decrease inpain, and functional improvement. Someinvestigators-' demonstrated that arthroscopicrelease was helpful in patients with diabetes-associated adhesive capsulitis who were refrac-tory to conservative measures. Thirteen of thepatients studied had no pain, full range ofmotion and full function after surgical release.

Interestingly, a marked discrepancy existsbetween the patient's subjective awareness ofresidual range deficit and the measurable(objective) restrictions. Many patients withrange deficits regard their recovery as com-

FIGURE 8. Anterior approach to glenohumeral joint injection for adhe-sive capsulitis.

plete. This difference in subjective and objec-tive assessment of recovery, plus the variationand confiasion in the definitions of adhesivecapsulitis, may account for the conflictingreports of prognosis a nd therapy.'REFERENCES

1. Neviaser jS, Adhesive capsulitis of the shoulder: astudy of the pathologic f indings in periarthrit is ofthe shoulder. J Bone Joint Surg 1 945;27;21 1 -22.

2. Neviaser JS, Adhesive capsulitis of the shoulderMed Times 1962;90:783-807.3. Grey RG. The natural history of " idiop athic " froze nshoulder J Sone Joint Surg [Am] 1 97e:60 ;564.4. Richards DB, Kibler W B. Sports related shoulder reha-bilitation, J Musculoskeletal Me d 1 997;1 4:44-63.5. Sm ith EC, Berry H, Scott D L, The dinical ne ed for

an acute rheu ma tolog y r eferral service. Br JRheumato l 1996;35:389-91.6. van der W ind t D A, Koes BW, de Jong BA, Bouter

LM, Shoulder disorders in general praaice. AnnRheum Dis 1995;54:959-64.7. Mode sto C, Crespo E, Vil las C, Aquerreta D , Adhe-

sive capsulitis. Is it possible in childhood? Scand JRheumato l 1995;24:255-6,8. RJzk TE, Pinals RS. Frozen should er. Sem in Art hr itis

Rheum 1982:11:440-S2.9- Reeves B, The natur al history of the frozen shou l-der syndrome. Scand J Rheumatol 1 975;4:1 93-6.

10. Binder Al, Bulgen DY, Hazleman BL, Roberts S.Frozen shoulder, Ann Rheum D is 198 4;43:361 -4.1 1 . Bulgen DY, Binder A, Hazleman BL, Park JR.Immunolog ica l s tud ies in f rozen shoulder. JRheumato l 1982;9:893-8.12. Neviaser RJ, Neviaser TJ, The frozen shoulder. D iagno-sis and management, Clin Orthop 1987;233;59-64.13. Emig EW , Schweitzer ME, Ksraslcl^ D , Lubow itz J.Adhesive capsulitis of the shoulder: MR diagnosis.

AJR Am i Roentgeno) 1 995; 1 64:1457-9.14. W ohlg eths n JR. Frozen shoulder in hyperthy -roidism. Arthrit is Rheum 1987;30:936-9.15- Arkkila PE, Kantola IM, Viikari JS, Ronnemaa T.Shoulder caps uiitis in type I and tl diabetic p atients.Ann Rheum Dis 1996:55:907-14.1 6. Bulgen DY, Binder Al, Hazleman BL, Du tton J,Roberts S. Frozen shoulder. Ann R heum D is1984:43:353-60,17. Mil ler MD , W irth MA, Rockwood CA Jr Thawingthe frozen shoulder. Orthopedics 1996:19:849-53.18 . Belzer JR D urkin RC. Com mo n disorders of theshoulder. Prim Care 1 996:23:3 65-88 ,19. Larson H M, O'C onno r FG, NirschI RP. Shoulder

pain: the role of diagnostic injections. Am Fam Phy-s ic ian 1996:53:1637-47,20. W arner JJ, Allen A, M arks PH. W ong P. Arthr o-scopic release for chronic, refractory adhesive cap-sutitis of the shoulder. J Bone Joint Surg [Am] 1 996:78 :1808 -16 ,21 . Ogilvie-Harris DJ, Myerthail S. The diabetic frozenshoulder. Arthroscopy 1997: 13:1-8.


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Adhesive capsulitis: A sticky issue

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