Synonym: adhesive capsulitis of the shoulder
Frozen shoulder is one of the most common causes of intrinsic shoulder pain. It is a glenohumeral disorder and can occur in one shoulder or both shoulders simultaneously. Thickening and contraction of the glenohumeral joint capsule and formation of adhesions cause pain and loss of movement.
Frozen shoulder can occur:
- Following rotator cuff lesions/injury.
- In conditions causing immobility - eg, after a cerebrovascular accident or plaster immobilisation.
- Most commonly, it affects ages 40-65 years; the median age is 50-55 years.
- It affects around 3% of the adult population.
- It is more common in women.
- The incidence of adhesive capsulitis is two to four times higher in those with diabetes than in the general population.
- It is also associated with thyroid disease.
- The vast majority of patients notice pain before stiffness.
- It usually affects the non-dominant shoulder although it can occur in either shoulder.
- Bilateral frozen shoulder occurs in around 14% of patients.
- There is usually a gradual onset of severe pain in the shoulder, which is associated with stiffness.
- Restriction of all shoulder movements, both active and passive.
- Inability to sleep on the affected side.
- Restriction of activities of daily living due to impaired external rotation - eg, driving, dressing.
- There tends to be three phases:
- Phase 1 - severe generalised pain associated with stiffness. Daily activities are limited (eg, putting on a jacket). It can last up to nine months.
- Phase 2 - pain usually gradually subsides but the shoulder is stiff. Movement can become more limited. External rotation is usually very limited. This phase lasts between 4-12 months.
- Phase 3 - the shoulder becomes less stiff. There is an increase in the range of movement. This phase usually lasts 1-3 years.
Stiffness, pain and loss of motion with insidious onset are usually the major symptoms.
- The diagnosis is clinical:
- The whole shoulder joint may be tender to palpation.
- The main diagnostic test is the inability to do passive external rotation.
- X-rays are usually only necessary if the presentation is atypical or the patient is not responding to treatment.
- X-rays are commonly normal.
- Consider other causes of shoulder pain.
- Blood tests and radiography should only be performed if red flag symptoms are present. For a list of these, refer to the separate Shoulder Pain article.
- Despite over a hundred years of treating this condition the most efficacious treatments are still largely unclear.
- An holistic approach to treatment should be used, considering psychological and psychosocial factors.
- The first stage is analgesia - paracetamol as first-line with non-steroidal anti-inflammatory drugs (NSAIDs) second-line, provided there are no contra-indications. Use of a transcutaneous electrical nerve stimulation (TENS) machine may also be helpful.
- Encourage early activity.
- Provide a written patient information leaflet on shoulder pain.
- Physiotherapy with joint mobilisation combined with stretching exercises has been shown to be better than stretching exercise alone in terms of external rotation, abduction range of motion and function score.
- Physiotherapy can prevent further reduction in range of motion and eventually increase the range of motion in the affected shoulder.
- Passive mobilisation and capsular stretching are two of the most commonly used techniques for physiotherapy.
- Injection with corticosteroids can reduce pain and duration of symptoms in the early stages.
- The best available data show that a combination of manual therapy and exercise may not actually be as effective as glucocorticoid injection in the short term.
- There is, however, no benefit of ultrasound-guided steroid injection.
- Oral steroids may provide short-term benefit in pain and function.
- Distension therapy involves injecting large volumes of fluid (saline or local anaesthetic, with or without steroid) into the shoulder joint, with the aim of distending or even rupturing the joint capsule.
- One study has shown that the most effective treatment for frozen shoulder was the combination of the intensive mobilisation and steroid injection with capsular distension, which helped to control inflammation, extend joint space and recover range of movement.
- Surgical treatment may be in the form of manipulation under anaesthesia (MUA), which involves passively moving the arm to tear the thickened inflamed coracohumeral and glenohumeral ligaments as well as stretch the capsule, or arthroscopic arthrolysis, which allows direct division of the involved ligaments and capsular release.
- The management of frozen shoulder amongst surgeons varies substantially.
Long-term pain and shoulder stiffness.
- Symptoms can persist for 18 months to three years or more.
- However, over 90% of patients with spontaneous frozen shoulder have been shown to recover to normal levels of function and movement by two years without any treatment.
- Consider referral to secondary care if pain and significant disability are present for more than six months despite appropriate conservative management.
- Relapses in the same shoulder are uncommon.
Whatever the reason, avoid prolonged immobilisation - eg, slings, plaster casts - during illness.
Further reading and references
Uddin MM, Khan AA, Haig AJ, et al; Presentation of frozen shoulder among diabetic and non-diabetic patients. J Clin Orthop Trauma. 2014 Dec5(4):193-8. doi: 10.1016/j.jcot.2014.09.008. Epub 2014 Oct 7.
Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder; Chartered Society of Physiotherapists, 2011
Smith CD, Hamer P, Bunker TD; Arthroscopic capsular release for idiopathic frozen shoulder with intra-articular injection and a controlled manipulation. Ann R Coll Surg Engl. 2014 Jan96(1):55-60. doi: 10.1308/003588414X13824511650452.
Guyver PM, Bruce DJ, Rees JL; Frozen shoulder - A stiff problem that requires a flexible approach. Maturitas. 2014 May78(1):11-6. doi: 10.1016/j.maturitas.2014.02.009. Epub 2014 Feb 28.
Celik D, Kaya Mutlu E; Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial. Clin Rehabil. 2015 Jul 30. pii: 0269215515597294.
Uppal HS, Evans JP, Smith C; Frozen shoulder: A systematic review of therapeutic options. World J Orthop. 2015 Mar 186(2):263-8. doi: 10.5312/wjo.v6.i2.263. eCollection 2015 Mar 18.
Page MJ, Green S, Kramer S, et al; Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2014 Aug 268:CD011275. doi: 10.1002/14651858.CD011275.
Bloom JE, Rischin A, Johnston RV, et al; Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev. 2012 Aug 158:CD009147.
Canbulat N, Eren I, Atalar AC, et al; Nonoperative treatment of frozen shoulder: oral glucocorticoids. Int Orthop. 2015 Feb39(2):249-54. doi: 10.1007/s00264-014-2650-1. Epub 2015 Jan 10.
Park SW, Lee HS, Kim JH; The effectiveness of intensive mobilization techniques combined with capsular distension for adhesive capsulitis of the shoulder. J Phys Ther Sci. 2014 Nov26(11):1767-70. doi: 10.1589/jpts.26.1767. Epub 2014 Nov 13.
Kwaees TA, Charalambous CP; Surgical and non-surgical treatment of frozen shoulder. Survey on surgeons treatment preferences. Muscles Ligaments Tendons J. 2015 Feb 54(4):420-4. eCollection 2014 Oct-Dec.
Vastamaki H, Kettunen J, Vastamaki M; The natural history of idiopathic frozen shoulder: a 2- to 27-year followup study. Clin Orthop Relat Res. 2012 Apr470(4):1133-43. Epub 2011 Nov 17.
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