Frozen Shoulder

Adhesive capsulitis of the shoulder or, as it is more commonly known, frozen shoulder, is a painful condition of the shoulder that most commonly affects women aged between 40 and 60 years old. This pathology can sometimes be the result of trauma (e.g. following a fracture around the shoulder) or even occur postoperatively (e.g. after arthroscopic shoulder surgery). It is not uncommon, however, that no precise etiology is determined (primary or idiopathic adhesive capsulitis). This shoulder condition has been associated with the presence of diabetes melitus (both types), thyroid disorders (especially autoimmune disease), Dupuytren’s disease, atherosclerotic disease and cervical disc disease. 

The shoulder joint, as is the case with all joints in the human body, is enveloped in a layer of fibrous tissue, the joint capsule. This is further enhanced by the glenohumeral ligaments and together function as static stabilizers to the shoulder joint limiting extreme, uncontrolled motion. They do, nevertheless, allow for a full, functional range of motion and some joint laxity. In frozen shoulder disease these capsuloligamentous structures become contracted and ungiving, leading to significant decrease in active and passive shoulder motion accompanied by pain of varying degree. 

The disease generally runs quite a long course in time and can be classified in three basic, clinical stages. The freezing or painful stage is characterized by gradual onset of diffuse pain and lasts from six weeks to nine months. The frozen or stiff stage follows where shoulder motion is greatly decreased thus affecting everyday living. This can last for four to nine months. Finally, the thawing stage begins which heralds the gradual return of shoulder motion and function over a period of five to twenty-six months. 

Common manifestations of frozen shoulder include insidious onset of generalized shoulder pain followed by limitation of shoulder motion affecting activities of daily living. Pain can be elicited when attempting to move the shoulder or even at rest, while it may also occur during the night making sleep a challenge. Clinical examination reveals loss of both active and passive shoulder motion, with a painful arc motion leading to a firm endpoint. Examining for other shoulder pathology, such as rotator cuff or biceps tendon disease, may be of limited clinical value due to pain and loss of motion. 

Imaging studies begin with a series of common radiographs to obtain information on the bony anatomy of the shoulder, such as the presence of disuse osteopenia or arthritis. A magnetic resonance imaging (MRI) with or without an arthrogram can be obtained when concomitant or alternative pathology is investigated as the cause of the patient’s symptoms but is not in and of itself necessary for the diagnosis of adhesive capsulitis, as this is mainly clinical. 

The management of frozen shoulder consists of both non-operative and operative modalities. The former are the first line of treatment and are effective in dealing with the pain and loss of mobility in the majority of cases. They involve physical means (heat and/or cryotherapy), painkillers, such as paracetamol and non-steroidal anti-inflammatory medications, as well as intra-articular injections of local anesthetic agents and corticosteroids. These help deal mainly with the initial painful phase, while corticosteroid injections can have a more prolonged analgesic/anti-inflammatory effect of up to several weeks. Moreover, physical therapy plays a quintessential part in managing this disease. It generally involves daily, progressive stretching exercises to the point of pain. The duration of therapy can last from three to six months, during which the patient must be supervised by a skilled physical therapist. This may be followed by a home-based program until optimal recovery is attained.   

Operative treatment is reserved for recalcitrant cases where conservative measures have failed to restore shoulder function to an acceptable degree, prohibiting patients from functioning effectively on a daily basis. Modalities under this category consist, firstly, of manipulation under anesthesia (MUA), whereby, under appropriate anesthesia and muscle relaxation, the patient’s shoulder is brought through as full an arc of motion as possible applying steady, controlled force. For this to be effective, various methods of post-procedural analgesia are implemented (oral, intravenous and/or intra-articular painkillers) in order to minimize pain and allow for early physical therapy to be commenced. In addition to MUA, especially if this fails to achieve any significant increase in shoulder range of motion, an arthroscopic capsular (i.e. soft tissue) release can be performed. This aims at releasing the thickened and contracted soft tissues impeding shoulder motion. As with MUA, early physical therapy is crucial to maintain the gains of this procedure. 

In conclusion, frozen shoulder or adhesive capsulitis is a painful, usually idiopathic yet, fortunately, self-limiting disease that commonly affects women with diabetes, thyroid or autoimmune disease. Its diagnosis is mainly clinical while its treatment is first and foremost non-operative, achieving good functional results in the majority of patients. In the few cases where conservative management fails, MUA or arthroscopic capsular release can succeed in restoring shoulder range of motion and functionality. In any case, it is important that a comprehensive physical therapy plan of appropriate duration is consistently implemented for the best possible results to be maintained.