Frozen Shoulder

Doc-examining-shoulder-xrayAnatomy of GHJ

Incidence & Prevalence of Adhesive Capsulitis

Adhesive capsulitis (also termed frozen shoulder, stiff painful shoulder or periarthritis) is a common cause of shoulder pain estimated to affect 2-5% of the general population (Anton 1993, Lundberg 1969) and up to 20% in those with diabetes (Manske and Prohaska 2008). The cumulative incidence of presentations to general practice from a Dutch study of shoulder complaints has been estimated to be 2.4/1000/year (95% CI 1.9-2.9) (van der Windt 1995).

Assessment: Signs and Symptoms

Duplay first described a condition of painful stiffening of the shoulder in 1872 (Duplay 1872). Since then other terms have been used to label this condition including ‘frozen shoulder’, to describe painful restriction of range of motion of the shoulder with normal plain roentgenographs (Codman 1934) and ‘adhesive capsulitis’, based upon the shoulder joint arthrographic findings (Neviaser 1945).

The disorder is characterised by spontaneous onset of shoulder pain and progressive global stiffness of the glenohumeral joint accompanied by significant disability (Reeves 1975; Neviaser 1987). Most studies have suggested a self-limiting condition lasting an average of two to three years although significant numbers of people have residual clinically detectable restriction of movement beyond three years and smaller numbers have residual disability (Reeves 1975; Grey 1978; Hazleman 1972; Clarke 1975; Binder 1984; Lloyd-Roberts 1959; Simmonds 1949).

Adhesive capsulitis presentation is generally broken into three distinct stages.

  1. The first stage that is described is called the freezing or painful stage. Patients may not present during this stage because they think that eventually the pain will resolve if self-treated. As the symptoms progress, pain worsens and both active and passive range of motion (ROM) becomes more restricted, eventually resulting in the patient seeking medical consultation. This phase typically lasts between 3 and 9 months and is characterised by an acute synovitis of the glenohumeral joint.
  2. The second stage is the frozen or transitional stage. During this stage shoulder pain does not necessarily worsen. Because of pain at end ROM, use of the arm may be limited causing muscular disuse. The frozen stage lasts anywhere 4 to 12 months. The common capsular pattern of limitation has historically been described as diminishing motions with external shoulder rotation being the most limited, followed closely by shoulder flexion, and internal rotation. There eventually becomes a point in the frozen stage that pain does not occur at the end of ROM.
  3. The third stage begins when ROM begins to improve. This 3rd stage is termed the thawing stage. This stage lasts anywhere from 12 to 42 months and is defined by a gradual return of shoulder mobility. (Manske and Prohaska 2008)

Diagnosis

The diagnosis of adhesive capsulitis is often one of exclusion. Early in the disease process adhesive capsulitis may clinically appear similar to other shoulder conditions such as major trauma, rotator cuff tear, rotator cuff contusion, labral tear, bone contusion, subacromial bursitis, cervical or peripheral neuropathy. Additionally, a history of a previous surgical procedure can lead to shoulder stiffness. A plain screening radiograph of the shoulder is important to rule out other causes of shoulder pain and stiffness such as fractures, dislocation, osteoarthritis, and red flags. If a history and clinical examination for these other pathologies are negative, then the diagnosis can be given (Manske and Prohaska 2008).

Management

Conservative management of adhesive capsulitis includes physiotherapy (exercise, manual therapy, massage, TENS, heat), anti-inflammatory medications. More invasive treatments included intra-articular corticosteroid injections, and capsular distension injections. Surgical treatment includes manipulation under anaesthetic, and arthroscopic release and repair (Buchbinder et al 2006).

Maund et al (2012) undertook a large systematic review and economic analysis of treatment for frozen shoulder. Physiotherapy combined with corticosteroid injection was the only treatment to be deemed significantly beneficial compared to placebo, however there was limited data on which to form conclusions and the authors recommend that further high quality research is needed in this area.