- Email: [email protected]
Adhesive Capsulitis of the Hip
Adhesive Capsulitis of the Hip J. W. Thomas Byrd, M.D., and Kay S. Jones, M.S.N., R.N.
Purpose: It is postulated that adhesive capsulitis of the hip is more common than suggested in the published literature, which recounts only a few isolated cases, and that this condition shares many of the same characteristics seen in the shoulder. The purpose of this study was to investigate and report the findings of the first clinical case series on this condition. Type of Study: Clinical case series, retrospective review of prospectively collected data. Methods: Since 1993, all hip arthroscopy cases have been prospectively assessed with a 100-point rating system. In 1999, adhesive capsulitis was first recognized as a causative factor. Since then, 9 patients have been identified with this condition with at least 1 year of follow-up. Results: There was 100% follow-up at an average of 17.3 months. The average age was 43.7 years. There were 8 women and 1 man. Radiographs were normal in 8 cases and revealed mild degenerative disease in the 1 male patient. Magnetic resonance imaging/ arthrography failed to reveal evidence of adhesive capsulitis. Examination under anesthesia revealed an average loss of 25° of rotational motion (19.4 external, 5.6° internal). Full range of motion was regained with manipulation. Arthroscopy revealed characteristic findings of adhesive capsulitis in all cases and coexistent pathology in 6 cases (5 articular lesions, 3 labral tears, and 1 ruptured ligamentum teres). The 8 women with normal radiographs all improved with an average of 32 points (preoperative, 56.4; postoperative, 88.4). The 1 man with degenerative changes showed negligible improvement. There were no complications. Conclusions: Adhesive capsulitis of the hip is not as rare as suggested by the paucity of available literature. The clinical characteristics are similar to the shoulder, principally consisting of painful restricted motion and a clear predilection for middle aged women. It may occur with or without associated intra-articular pathology. Arthroscopy can be beneficial in the treatment of recalcitrant cases, but may assume less of a role with improved diagnostic skills essential to implementing a proper management strategy. Level of Evidence: Level IV. Key Words: Hip—Adhesive capsulitis—Arthroscopy.
T
here are a few reports on adhesive capsulitis of the hip, and the collective literature is brief.1-7 In 1999, these authors first recognized adhesive capsulitis in a patient undergoing arthroscopy. Subsequent experience led them to speculate that this condition may be more common than suggested by the paucity of literature and that it may share clinical features encountered in the shoulder. The purpose of this arti-
From the Nashville Sports Medicine & Orthopaedic Center and the Department of Orthopaedics and Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A. Address correspondence and reprint requests to J. W. Thomas Byrd, M.D., Nashville Sports Medicine & Orthopaedic Center, 2011 Church St, Suite 100, Nashville, TN 37203, U.S.A. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America 0749-8063/06/2201-4466$32.00/0 doi:10.1016/j.arthro.2005.10.009
cle is to report on these authors’ arthroscopic experience in the treatment of patients with a diagnosis of adhesive capsulitis of the hip. METHODS Since 1993, all patients undergoing hip arthroscopy have been prospectively assessed using a previously published format, which includes a modified Harris Hip Score.8 Data were obtained preoperatively and then postoperatively at 3, 12, 24, and 60 months. At the time of this reporting, the database consists of 612 consecutive cases. In 1999, adhesive capsulitis was first identified in a patient undergoing arthroscopy. This is characterized by restricted range of motion when examined under anesthesia without structural cause (i.e., degenerative disease or impingement) and the arthroscopic finding of characteristic capsular fi-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 1 (January), 2006: pp 89-94
89
90
J. W. T. BYRD AND K. S. JONES
FIGURE 1. With the affected hip in a figure-of-4 position, downward manual pressure is applied to the medial side of the ipsilateral knee. With gentle constant pressure, crepitus can be felt and heard, characteristic of the disrupting adhesions. The knee will lower closer to the table, equal to the unaffected side. Once the characteristic capsular pattern of constriction has been released, it is then easier to further stretch the hip in internal and external rotation, achieving full passive range of motion.
TABLE 1.
brosis. Subsequently, a total of 9 cases have been recognized with a minimum 1 year of follow-up. This cohort represents the substance of this study. All patients were assessed by the senior author, including history, examination, and standard radiographs (anteroposterior pelvis film including both hips, and frog lateral of the affected hip). Further investigative studies were not standardized. Most patients were referred for treatment having already undergone various imaging studies. Repeat or adjunct studies were obtained as deemed necessary for the individual clinical circumstances. The indication for arthroscopy was either intractable hip pain unresponsive to conservative measures or imaging evidence of intra-articular pathology amenable to arthroscopy. Conservative treatment included lifestyle modifications to avoid pain-provoking activities, supervised physical therapy, and oral anti-inflammatory medications. All procedures were performed by the senior author using the following protocol: Under general anesthesia, examination is performed followed by manipulation and then arthroscopy. Internal and external rotation are recorded with the hip in 90° of flexion. Flexion and extension are not Results Duration of Conservative Treatment (mo)
Side
Onset of Symptoms
Duration of Symptoms (mo)
F
Left
Insidious
14
8
Normal
Normal
42
F
Right
Acute
4
3
Normal
Normal
3
41
F
Right
Insidious
19
12
Normal
4
42
F
Left
Acute
12
2
Normal
Effusion, anterior labral tear, chondromalacia acetabulum Anterior labral tear
5
36
F
Right
Traumatic
10
8
Normal
Normal
6
49
F
Right
Traumatic
21
18
Normal
Normal
7
55
M
Right
Insidious
7
6
Effusion
8
47
F
Left
Acute
6
4
Mild degenerative changes; slight joint space narrowing Normal
9
42
F
Right
Insidious
15
6
NA
NA
Case
Age (yr)
Sex
1
39
2
Radiographic Findings
MRI Findings
NA
ADHESIVE CAPSULITIS OF THE HIP routinely recorded because of the inconsistencies of measurement created by associated pelvic tilt. Manipulation is then performed by placing the affected hip in a figure-of-4 position and applying downward manual pressure to the medial side of the knee (Fig 1). During manipulation, the pelvis is stabilized simply by the weight of the torso; applying manual counterpressure to the opposite side of the pelvis is not necessary. It is felt that performing the manipulation only against the weight of trunk lessens the risk of exerting too much force and possibly fracturing the femoral neck. Characteristic crepitations can be felt with disruption of the adhesions. Following this maneuver, gentle stretching then regains full internal and external rotation. The arthroscopic procedure is subsequently performed using the standard 3-portal supine technique previously described.9,10 Coexistent pathology is identified and addressed, including labral debridement, chondroplasty, and excision of diseased tissue from the acetabular fossa. Postoperatively, crutches are used for 5 to 7 days until the patient’s gait pattern is normalized. Physical therapy is begun on the second postoperative day, emphasizing range of motion, muscle toning, and
TABLE 1.
MRA Findings
Response to Injection
Anterior labral tear
Positive
Normal
Positive
NA
Positive
Anterior labral tear Normal
Positive
Normal
Positive
NA
NA
Normal
Positive
Normal
Positive
Positive
Range of Motion Under Anesthesia (normal side) 40°ER; 10° IR (55°/ 20°) 50°ER; 10°IR (60°/20°) 30°ER; 20°IR (55°/20°) 30°ER; 10°IR (50°/20°) 35°ER; 10°IR (55°/20°) 35°ER; 15°IR (60°/20°) 20°ER; 10°IR (35°/10°)
35°ER; 20°IR (60°/20°) 30°ER; 12°IR (50°/20°)
91
closed-chain exercises as tolerated to regain independence with normal daily activities.11 Functional exercises are then progressed from 1 to 3 months, dictated by the patient’s response. RESULTS The results are summarized in Table 1. There was 100% follow-up at an average of 17.3 months (range, 12 to 24 months). There were 8 women and 1 man with an average age of 43.7 years (range, 36 to 55 years). There were 6 right and 3 left hips. Two patients sustained a specific traumatic event, falling on a hard surface. Three patients described an acute twisting episode that initiated their symptoms, and 4 patients described insidious onset in the absence of a defined moment. The duration of symptoms before arthroscopy averaged 12 months (range, 4 to 21 months) and the duration of conservative treatment averaged 7.4 months (range, 2 to 18 months). In all cases, the principal examination finding was painful range of motion with guarding of the affected hip. Radiographs were normal in 8 cases and showed mild degenerative disease in the 1 male patient. Eight
Continued
Preop Score
Postop Score
Change in Score
Follow-up (mo)
Adhesive capsulitis; partial rupture ligamentum teres
63
85
22
12
Adhesive capsulitis; grade III chondral lesion acetabulum Adhesive capsulitis; tear anterior labrum; grade III chondral lesion acetabulum Adhesive capsulitis
54
81
27
12
51
81
30
12
57
100
43
24
Adhesive capsulitis; tear lateral labrum; grade III chondral lesion acetabulum Adhesive capsulitis
63
96
33
24
47
83
36
24
Adhesive capsulitis; tear anterior & lateral labrum; grade IV chondral lesion acetabulum & femoral head Adhesive capsulitis
78
79
1
12
61
85
24
12
Adhesive capsulitis; tear anterior labrum; grade IV chondral lesion acetabulum
55
96
41
24
Arthroscopic Diagnosis
92
J. W. T. BYRD AND K. S. JONES 2). None of the studies revealed evidence suggesting adhesive capsulitis. None of these patients had other significant comorbid medical conditions. Examination under anesthesia revealed restricted rotational motion in all patients, with an average loss of 19.4° of external rotation (range, 10° to 25°) and 5.6° of internal rotation (range, 0° to 10°). Full range of motion was regained with manipulation. Arthroscopy revealed characteristic findings of adhesive capsulitis, including hemorrhagic fibrinous debris within the pericapsular recesses and acetabular fossa (Fig 3). Other coexistent intra-articular pathology was present in 6 cases and included 5 articular lesions, 4 labral tears, and 1 partial disruption of the ligamentum teres. Among the 8 women with normal radiographs, the average preoperative score was 56.4 points and postoperative was 88.4, representing an average improvement of 32 points (range, 22-43). The 1 male with degenerative disease had negligible improvement (preoperative, 78; postoperative, 79). There were no complications. DISCUSSION
FIGURE 2. Sagittal fat-suppressed T1-weighted MRA image of a left hip shows an anterior labral tear (arrow).
patients had an intra-articular injection of anesthetic that provided temporary alleviation of their symptoms. Among 7 magnetic resonance imaging (MRI) studies, 2 showed an effusion and 1 revealed evidence of an articulolabral lesion. Among 7 MR arthrograms (MRA), 2 showed evidence of labral pathology (Fig
Adhesive capsulitis of the hip was first recognized as a clinical entity by these authors in 1999. In retrospect, it is likely that this condition had been previously encountered, but not recognized. As has been stated, “The eyes cannot see what the mind does not know.” Based on these current observations, it is likely that adhesive capsulitis of the hip is more common than suggested by the lack of literature on this topic. The history of injury is variable and of no specific diagnostic value. The principal examination finding is painful restricted motion. However, this observation
FIGURE 3. Arthroscopic view of a left hip from the anterolateral portal illustrates the characteristic hemorrhagic fibrinous debris (A) obliterating the acetabular fossa (asterisk) and (B) present in the pericapsular recess (asterisks) peripheral to the labrum (L).
ADHESIVE CAPSULITIS OF THE HIP can be nonspecific in the presence of joint pathology where motion may be self-limited secondary to pain or structurally restricted from an entrapped fragment or advanced degeneration. The radiographs were normal in 8 of 9 cases and this is consistent with the literature. Radiographic abnormalities have generally been reported only when there is underlying disease that leads to adhesive capsulitis.2,3 Murphy et al.2 reported a case in which adhesive capsulitis was diagnosed by “tightness during arthrography.”2 Lequesne et al.3 further proposed that arthrography was a valuable method for diagnosing reduced articular capacity. However, this observation was often subtle in cases of idiopathic capsular constriction usually requiring contralateral arthrography for comparison. In this current study, reduced capsular volume was not documented in any case preoperatively, although no contralateral injections were performed for comparison. The literature supports that adhesive capsulitis may occur as an idiopathic primary phenomenon or secondary to underlying joint pathology, most commonly synovial chondromatosis.2-4 Often, the underlying pathology required surgical intervention while idiopathic cases would respond to conservative treatment over a protracted period of time ranging from 5 to 24 months. It is worthwhile to note that with the greater sensitivity of current investigative methods such as MRI and MRA, more subtle joint pathology may be detected. This may facilitate earlier intervention for recalcitrant cases, but also raises the question of whether some of these might potentially become quiescent, given enough time. Mont et al.6 reported a case in which arthroscopy was attempted and failed in the presence of adhesive capsulitis. In this present series, arthroscopy was effectively performed in all cases. However, it is an important technical point that manipulation was performed before arthroscopy. It is likely that distraction of the joint would be much more difficult without prior manipulation and could heighten the potential for iatrogenic damage or a failed procedure. Eight of 9 patients were middle-aged women ranging in age from 36 to 49 years, all with normal radiographs. This demographic distribution is similar to the population believed to be most at risk of developing adhesive capsulitis of the shoulder.12 The only outlier was a 55-year-old man with mild associated degenerative changes. This patient also had the poorest result. None of these patients had other comorbid medical conditions typically associated with adhesive
93
capsulitis, but this cohort is too small to draw any reliable conclusions on this aspect. Based on this preliminary experience, it is likely that adhesive capsulitis of the hip is more common than is suggested in the literature. McGrory and Endrizzi7 postulated that it is less frequently diagnosed than the shoulder because limited hip motion is not as much of a functional problem. This observation is similar to the concepts proposed by Griffin et al. in rehabilitation of hip disorders.11 For most hip conditions, range of motion is only modestly emphasized to avoid exacerbating underlying symptoms because restricted motion is much better tolerated in the hip than other joints, such as the shoulder and knee. The literature supports that many cases of primary adhesive capsulitis will respond to conservative treatment.3-5,7 With a better understanding of this process and cautious interpretation of investigative studies, it is likely that establishing this diagnosis will aid clinicians in structuring a properly directed conservative rehabilitation program. Adhesive capsulitis of the hip is a clearly identifiable entity. The clinical characteristics are similar to those commonly attributed to this condition in the shoulder. A history of injury is variable and the principal physical finding is painful restricted motion. There is a clear predilection for middle-aged women and the condition may occur with or without associated intra-articular pathology. For recalcitrant cases, manipulation under anesthesia and concomitant arthroscopy is an effective form of treatment. Arthroscopy will reveal characteristic hemorrhagic fibrinous debris and allow assessment and management of coexistent damage.
REFERENCES 1. Caroit M, Djian A, Hubault A, Normandin C, De S’eze S. Revue du rhumatisme et des maladies osteo-articulaires. Rev du Rhumatisme 1963;30;784-789. 2. Murphy WA, Siegel MJ, Gilula LA. Arthrography in the diagnosis of unexplained chronic hip pain with regional osteopenia. AJR Am J Roentgenol 1977;129:283-287. 3. Lequesne M, Becker J, Bard M, Witvoet J, Postel M. Capsular constriction of the hip: Arthrographic and clinical considerations. Skeletal Radiol 1981;6:1-10. 4. Griffiths JH, Utz R, Burke J, Bonfiglio T. Adhesive capsulitis of the hip and ankle. AJR Am J Roentgenol 1985;144:101-105. 5. Modesto C, Crespo E, Villas C, Aquerreta D. Adhesive capsulitis: Is it possible in childhood? Scand J Rheumtaol 1995; 24:255-256. 6. Mont MA, Lindsey JM, Hungerford DS. Adhesive capsulitis of the hip. Orthopedics 1999;22:343-345. 7. McGrory BJ, Endrizzi DP. Adhesive capsulitis of the hip after
94
J. W. T. BYRD AND K. S. JONES
bilateral adhesive capsulitis of the shoulder. Am J Orthop 2000;457-460. 8. Byrd JWT, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy 2000;16:578-587. 9. Byrd JWT. Hip arthroscopy utilizing the supine position. Arthroscopy 1994;10:275-280.
10. Byrd JWT. Hip arthroscopy: The supine position. Instr Course Lect 2003;52:721-730. 11. Griffin KM, Henry CO, Byrd JWT. Rehabilitation after hip arthroscopy. J Sports Rehabil 2000;9:77-88. 12. Hannafin JA, Chiaia TA. Adhesive capsulitis. a treatment approach. Clin Orthop 2000;372:95-109.
Purpose: It is postulated that adhesive capsulitis of the hip is more common than suggested in the published literature, which recounts only a few isolated cases, and that this condition shares many of the same characteristics seen in the shoulder. The purpose of this study was to investigate and report the findings of the first clinical case series on this condition. Type of Study: Clinical case series, retrospective review of prospectively collected data. Methods: Since 1993, all hip arthroscopy cases have been prospectively assessed with a 100-point rating system. In 1999, adhesive capsulitis was first recognized as a causative factor. Since then, 9 patients have been identified with this condition with at least 1 year of follow-up. Results: There was 100% follow-up at an average of 17.3 months. The average age was 43.7 years. There were 8 women and 1 man. Radiographs were normal in 8 cases and revealed mild degenerative disease in the 1 male patient. Magnetic resonance imaging/ arthrography failed to reveal evidence of adhesive capsulitis. Examination under anesthesia revealed an average loss of 25° of rotational motion (19.4 external, 5.6° internal). Full range of motion was regained with manipulation. Arthroscopy revealed characteristic findings of adhesive capsulitis in all cases and coexistent pathology in 6 cases (5 articular lesions, 3 labral tears, and 1 ruptured ligamentum teres). The 8 women with normal radiographs all improved with an average of 32 points (preoperative, 56.4; postoperative, 88.4). The 1 man with degenerative changes showed negligible improvement. There were no complications. Conclusions: Adhesive capsulitis of the hip is not as rare as suggested by the paucity of available literature. The clinical characteristics are similar to the shoulder, principally consisting of painful restricted motion and a clear predilection for middle aged women. It may occur with or without associated intra-articular pathology. Arthroscopy can be beneficial in the treatment of recalcitrant cases, but may assume less of a role with improved diagnostic skills essential to implementing a proper management strategy. Level of Evidence: Level IV. Key Words: Hip—Adhesive capsulitis—Arthroscopy.
T
here are a few reports on adhesive capsulitis of the hip, and the collective literature is brief.1-7 In 1999, these authors first recognized adhesive capsulitis in a patient undergoing arthroscopy. Subsequent experience led them to speculate that this condition may be more common than suggested by the paucity of literature and that it may share clinical features encountered in the shoulder. The purpose of this arti-
From the Nashville Sports Medicine & Orthopaedic Center and the Department of Orthopaedics and Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee, U.S.A. Address correspondence and reprint requests to J. W. Thomas Byrd, M.D., Nashville Sports Medicine & Orthopaedic Center, 2011 Church St, Suite 100, Nashville, TN 37203, U.S.A. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America 0749-8063/06/2201-4466$32.00/0 doi:10.1016/j.arthro.2005.10.009
cle is to report on these authors’ arthroscopic experience in the treatment of patients with a diagnosis of adhesive capsulitis of the hip. METHODS Since 1993, all patients undergoing hip arthroscopy have been prospectively assessed using a previously published format, which includes a modified Harris Hip Score.8 Data were obtained preoperatively and then postoperatively at 3, 12, 24, and 60 months. At the time of this reporting, the database consists of 612 consecutive cases. In 1999, adhesive capsulitis was first identified in a patient undergoing arthroscopy. This is characterized by restricted range of motion when examined under anesthesia without structural cause (i.e., degenerative disease or impingement) and the arthroscopic finding of characteristic capsular fi-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 1 (January), 2006: pp 89-94
89
90
J. W. T. BYRD AND K. S. JONES
FIGURE 1. With the affected hip in a figure-of-4 position, downward manual pressure is applied to the medial side of the ipsilateral knee. With gentle constant pressure, crepitus can be felt and heard, characteristic of the disrupting adhesions. The knee will lower closer to the table, equal to the unaffected side. Once the characteristic capsular pattern of constriction has been released, it is then easier to further stretch the hip in internal and external rotation, achieving full passive range of motion.
TABLE 1.
brosis. Subsequently, a total of 9 cases have been recognized with a minimum 1 year of follow-up. This cohort represents the substance of this study. All patients were assessed by the senior author, including history, examination, and standard radiographs (anteroposterior pelvis film including both hips, and frog lateral of the affected hip). Further investigative studies were not standardized. Most patients were referred for treatment having already undergone various imaging studies. Repeat or adjunct studies were obtained as deemed necessary for the individual clinical circumstances. The indication for arthroscopy was either intractable hip pain unresponsive to conservative measures or imaging evidence of intra-articular pathology amenable to arthroscopy. Conservative treatment included lifestyle modifications to avoid pain-provoking activities, supervised physical therapy, and oral anti-inflammatory medications. All procedures were performed by the senior author using the following protocol: Under general anesthesia, examination is performed followed by manipulation and then arthroscopy. Internal and external rotation are recorded with the hip in 90° of flexion. Flexion and extension are not Results Duration of Conservative Treatment (mo)
Side
Onset of Symptoms
Duration of Symptoms (mo)
F
Left
Insidious
14
8
Normal
Normal
42
F
Right
Acute
4
3
Normal
Normal
3
41
F
Right
Insidious
19
12
Normal
4
42
F
Left
Acute
12
2
Normal
Effusion, anterior labral tear, chondromalacia acetabulum Anterior labral tear
5
36
F
Right
Traumatic
10
8
Normal
Normal
6
49
F
Right
Traumatic
21
18
Normal
Normal
7
55
M
Right
Insidious
7
6
Effusion
8
47
F
Left
Acute
6
4
Mild degenerative changes; slight joint space narrowing Normal
9
42
F
Right
Insidious
15
6
NA
NA
Case
Age (yr)
Sex
1
39
2
Radiographic Findings
MRI Findings
NA
ADHESIVE CAPSULITIS OF THE HIP routinely recorded because of the inconsistencies of measurement created by associated pelvic tilt. Manipulation is then performed by placing the affected hip in a figure-of-4 position and applying downward manual pressure to the medial side of the knee (Fig 1). During manipulation, the pelvis is stabilized simply by the weight of the torso; applying manual counterpressure to the opposite side of the pelvis is not necessary. It is felt that performing the manipulation only against the weight of trunk lessens the risk of exerting too much force and possibly fracturing the femoral neck. Characteristic crepitations can be felt with disruption of the adhesions. Following this maneuver, gentle stretching then regains full internal and external rotation. The arthroscopic procedure is subsequently performed using the standard 3-portal supine technique previously described.9,10 Coexistent pathology is identified and addressed, including labral debridement, chondroplasty, and excision of diseased tissue from the acetabular fossa. Postoperatively, crutches are used for 5 to 7 days until the patient’s gait pattern is normalized. Physical therapy is begun on the second postoperative day, emphasizing range of motion, muscle toning, and
TABLE 1.
MRA Findings
Response to Injection
Anterior labral tear
Positive
Normal
Positive
NA
Positive
Anterior labral tear Normal
Positive
Normal
Positive
NA
NA
Normal
Positive
Normal
Positive
Positive
Range of Motion Under Anesthesia (normal side) 40°ER; 10° IR (55°/ 20°) 50°ER; 10°IR (60°/20°) 30°ER; 20°IR (55°/20°) 30°ER; 10°IR (50°/20°) 35°ER; 10°IR (55°/20°) 35°ER; 15°IR (60°/20°) 20°ER; 10°IR (35°/10°)
35°ER; 20°IR (60°/20°) 30°ER; 12°IR (50°/20°)
91
closed-chain exercises as tolerated to regain independence with normal daily activities.11 Functional exercises are then progressed from 1 to 3 months, dictated by the patient’s response. RESULTS The results are summarized in Table 1. There was 100% follow-up at an average of 17.3 months (range, 12 to 24 months). There were 8 women and 1 man with an average age of 43.7 years (range, 36 to 55 years). There were 6 right and 3 left hips. Two patients sustained a specific traumatic event, falling on a hard surface. Three patients described an acute twisting episode that initiated their symptoms, and 4 patients described insidious onset in the absence of a defined moment. The duration of symptoms before arthroscopy averaged 12 months (range, 4 to 21 months) and the duration of conservative treatment averaged 7.4 months (range, 2 to 18 months). In all cases, the principal examination finding was painful range of motion with guarding of the affected hip. Radiographs were normal in 8 cases and showed mild degenerative disease in the 1 male patient. Eight
Continued
Preop Score
Postop Score
Change in Score
Follow-up (mo)
Adhesive capsulitis; partial rupture ligamentum teres
63
85
22
12
Adhesive capsulitis; grade III chondral lesion acetabulum Adhesive capsulitis; tear anterior labrum; grade III chondral lesion acetabulum Adhesive capsulitis
54
81
27
12
51
81
30
12
57
100
43
24
Adhesive capsulitis; tear lateral labrum; grade III chondral lesion acetabulum Adhesive capsulitis
63
96
33
24
47
83
36
24
Adhesive capsulitis; tear anterior & lateral labrum; grade IV chondral lesion acetabulum & femoral head Adhesive capsulitis
78
79
1
12
61
85
24
12
Adhesive capsulitis; tear anterior labrum; grade IV chondral lesion acetabulum
55
96
41
24
Arthroscopic Diagnosis
92
J. W. T. BYRD AND K. S. JONES 2). None of the studies revealed evidence suggesting adhesive capsulitis. None of these patients had other significant comorbid medical conditions. Examination under anesthesia revealed restricted rotational motion in all patients, with an average loss of 19.4° of external rotation (range, 10° to 25°) and 5.6° of internal rotation (range, 0° to 10°). Full range of motion was regained with manipulation. Arthroscopy revealed characteristic findings of adhesive capsulitis, including hemorrhagic fibrinous debris within the pericapsular recesses and acetabular fossa (Fig 3). Other coexistent intra-articular pathology was present in 6 cases and included 5 articular lesions, 4 labral tears, and 1 partial disruption of the ligamentum teres. Among the 8 women with normal radiographs, the average preoperative score was 56.4 points and postoperative was 88.4, representing an average improvement of 32 points (range, 22-43). The 1 male with degenerative disease had negligible improvement (preoperative, 78; postoperative, 79). There were no complications. DISCUSSION
FIGURE 2. Sagittal fat-suppressed T1-weighted MRA image of a left hip shows an anterior labral tear (arrow).
patients had an intra-articular injection of anesthetic that provided temporary alleviation of their symptoms. Among 7 magnetic resonance imaging (MRI) studies, 2 showed an effusion and 1 revealed evidence of an articulolabral lesion. Among 7 MR arthrograms (MRA), 2 showed evidence of labral pathology (Fig
Adhesive capsulitis of the hip was first recognized as a clinical entity by these authors in 1999. In retrospect, it is likely that this condition had been previously encountered, but not recognized. As has been stated, “The eyes cannot see what the mind does not know.” Based on these current observations, it is likely that adhesive capsulitis of the hip is more common than suggested by the lack of literature on this topic. The history of injury is variable and of no specific diagnostic value. The principal examination finding is painful restricted motion. However, this observation
FIGURE 3. Arthroscopic view of a left hip from the anterolateral portal illustrates the characteristic hemorrhagic fibrinous debris (A) obliterating the acetabular fossa (asterisk) and (B) present in the pericapsular recess (asterisks) peripheral to the labrum (L).
ADHESIVE CAPSULITIS OF THE HIP can be nonspecific in the presence of joint pathology where motion may be self-limited secondary to pain or structurally restricted from an entrapped fragment or advanced degeneration. The radiographs were normal in 8 of 9 cases and this is consistent with the literature. Radiographic abnormalities have generally been reported only when there is underlying disease that leads to adhesive capsulitis.2,3 Murphy et al.2 reported a case in which adhesive capsulitis was diagnosed by “tightness during arthrography.”2 Lequesne et al.3 further proposed that arthrography was a valuable method for diagnosing reduced articular capacity. However, this observation was often subtle in cases of idiopathic capsular constriction usually requiring contralateral arthrography for comparison. In this current study, reduced capsular volume was not documented in any case preoperatively, although no contralateral injections were performed for comparison. The literature supports that adhesive capsulitis may occur as an idiopathic primary phenomenon or secondary to underlying joint pathology, most commonly synovial chondromatosis.2-4 Often, the underlying pathology required surgical intervention while idiopathic cases would respond to conservative treatment over a protracted period of time ranging from 5 to 24 months. It is worthwhile to note that with the greater sensitivity of current investigative methods such as MRI and MRA, more subtle joint pathology may be detected. This may facilitate earlier intervention for recalcitrant cases, but also raises the question of whether some of these might potentially become quiescent, given enough time. Mont et al.6 reported a case in which arthroscopy was attempted and failed in the presence of adhesive capsulitis. In this present series, arthroscopy was effectively performed in all cases. However, it is an important technical point that manipulation was performed before arthroscopy. It is likely that distraction of the joint would be much more difficult without prior manipulation and could heighten the potential for iatrogenic damage or a failed procedure. Eight of 9 patients were middle-aged women ranging in age from 36 to 49 years, all with normal radiographs. This demographic distribution is similar to the population believed to be most at risk of developing adhesive capsulitis of the shoulder.12 The only outlier was a 55-year-old man with mild associated degenerative changes. This patient also had the poorest result. None of these patients had other comorbid medical conditions typically associated with adhesive
93
capsulitis, but this cohort is too small to draw any reliable conclusions on this aspect. Based on this preliminary experience, it is likely that adhesive capsulitis of the hip is more common than is suggested in the literature. McGrory and Endrizzi7 postulated that it is less frequently diagnosed than the shoulder because limited hip motion is not as much of a functional problem. This observation is similar to the concepts proposed by Griffin et al. in rehabilitation of hip disorders.11 For most hip conditions, range of motion is only modestly emphasized to avoid exacerbating underlying symptoms because restricted motion is much better tolerated in the hip than other joints, such as the shoulder and knee. The literature supports that many cases of primary adhesive capsulitis will respond to conservative treatment.3-5,7 With a better understanding of this process and cautious interpretation of investigative studies, it is likely that establishing this diagnosis will aid clinicians in structuring a properly directed conservative rehabilitation program. Adhesive capsulitis of the hip is a clearly identifiable entity. The clinical characteristics are similar to those commonly attributed to this condition in the shoulder. A history of injury is variable and the principal physical finding is painful restricted motion. There is a clear predilection for middle-aged women and the condition may occur with or without associated intra-articular pathology. For recalcitrant cases, manipulation under anesthesia and concomitant arthroscopy is an effective form of treatment. Arthroscopy will reveal characteristic hemorrhagic fibrinous debris and allow assessment and management of coexistent damage.
REFERENCES 1. Caroit M, Djian A, Hubault A, Normandin C, De S’eze S. Revue du rhumatisme et des maladies osteo-articulaires. Rev du Rhumatisme 1963;30;784-789. 2. Murphy WA, Siegel MJ, Gilula LA. Arthrography in the diagnosis of unexplained chronic hip pain with regional osteopenia. AJR Am J Roentgenol 1977;129:283-287. 3. Lequesne M, Becker J, Bard M, Witvoet J, Postel M. Capsular constriction of the hip: Arthrographic and clinical considerations. Skeletal Radiol 1981;6:1-10. 4. Griffiths JH, Utz R, Burke J, Bonfiglio T. Adhesive capsulitis of the hip and ankle. AJR Am J Roentgenol 1985;144:101-105. 5. Modesto C, Crespo E, Villas C, Aquerreta D. Adhesive capsulitis: Is it possible in childhood? Scand J Rheumtaol 1995; 24:255-256. 6. Mont MA, Lindsey JM, Hungerford DS. Adhesive capsulitis of the hip. Orthopedics 1999;22:343-345. 7. McGrory BJ, Endrizzi DP. Adhesive capsulitis of the hip after
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bilateral adhesive capsulitis of the shoulder. Am J Orthop 2000;457-460. 8. Byrd JWT, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy 2000;16:578-587. 9. Byrd JWT. Hip arthroscopy utilizing the supine position. Arthroscopy 1994;10:275-280.
10. Byrd JWT. Hip arthroscopy: The supine position. Instr Course Lect 2003;52:721-730. 11. Griffin KM, Henry CO, Byrd JWT. Rehabilitation after hip arthroscopy. J Sports Rehabil 2000;9:77-88. 12. Hannafin JA, Chiaia TA. Adhesive capsulitis. a treatment approach. Clin Orthop 2000;372:95-109.