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Adhesive capsulitis ( Frozen shoulder )

Frozen shoulder ( Codman 1934 ) also known as adhesive capsulitis ( AC ) is a 
common painful , disabling and debilitating shoulder condition which is commonly managed in primary care.

 

incidence is likely to be 2 % to 5 % worldwide presents in the age group 40-70 ( uncommon before 40 ) unusual in patients > 70 ( excluding secondary traumatic AC ) slightly more common in women and peak age has been reported to be 56 yrs non- dominant shoulder is more likely to be affected , but b/l involvement has been reported in up to 40 % to 50 % cases incidence in those suffering with thyroid problems or diabetes can be as high as 10 % to 38 % ( patient with diabetes also are likely to face worse treatment outcomes based on duration of their diabetes ) no racial predilection.

 

Primary -idiopathic risk factors for primary AC include diabetes , thyroid disorders , rheumatoid arthritis , gout , hyperlipidaemia , Parkinson’s disease , cardiopulmonary disease , hypoadrenalism , duputyrens disease of hand normal radiographs

 

Secondary-identifiable traumatic or non traumatic shoulder pathology pre-existing shoulder disorders non-traumatic ( OA , RC tendinopathy, calcific tendinitis ) shoulder trauma ( fracture , dislocation , soft tissue injury ) post- mastectomy from breast cancer can also be seen as a complication of shoulder / non- shoulder surgery.

What happens aetiology is poorly understood presence of inflammation , scarring , fibrosis is supported hence it can be said that AC is an inflammatory joint condition – it results from a complex chain of events starting with inflammation , leading to fibrosis , contracture of the shoulder capsule ( inflammatory- fibrotic cascade ) macroscopic and histological features of the capsular contractures are well defined inflammatory contracture -reduction in joint volume -> limits glenohumeral movement during arthroscopy changes noted can include subacromial fibrosis , proliferative synovitis , capsular thickening , no adhesions contracture is a striking feature of the condition and ” contracted shoulder ” term is also used to describe the condition.

 

common condition which affects mostly people of working age definition, diagnosis , pathology and ideal / most efficacious treatment remains unclear shoulder problems account for 2.4 % of all GP consultations in the UK and 4.5 million visits to physicians in the USA cause for sick leave /absence from work a significant proportion of patients with AC do not seek medical attention recurrence / similar problem in other shoulder is common.

Painful/ freezing form -pain precedes reduced ROM diffuse disabling pain which is worse at night with further progression to pain at rest pain worse on lying on the affected side gradual loss of ROM particularly external rotation no identifiable event causing the pain can last 2-9 months.

 

Frozen adhesive stage -pain decreases progressively ( dull ache ) stiffness persists with considerable restriction in ROM pain at the end limits of motion immobility and functional limitations persist & the individual may see help during this phase due to difficulty in using the arm and loss of function lasts 4- 12 months

 

Thawing -gradual restoration of normal movement and less discomfort resolution of stiffness little / no pain lasts 12 – 42 months ( described variably in literature for e,g 5 – 26 months )

 

considerable overlap between the phases is seen , ie identifying which phase the patient is presenting with may not be that clear an alternative way to classify presentation can be to label the condition as pain predominant and stiffness predominant phases.

 

Presentation -sudden onset unilateral anterior shoulder pain pain is of deep seated burning nature intense pain which disturbs sleep ( key diagnostic feature ) painful selective restriction of certain active and passive movements of the shoulder ( loss of passive ROM is external rotation is usually the first motion affected followed by steady global loss of ROM ( some restriction of abduction and least affection of internal rotation carried passively – a capsular pattern ) stretching of the capsule cause pain to be worse at the extremes of motion patients may report problem with activities as
○ limited reach -overhead activities as hanging clothes
○ side activities as fastening seat belts
○ personal hygiene , clothing , brushing hairs.

 

location , duration , onset dominant or non dominant arm unable to lie on the affected side occupation and impact on daily living / work is the patient diabetic ? other associations as CV disease.

 

look- feel – move observe for muscle wasting alignment palpate ( including scapular , cervical , shoulder girdle regions ) 
○ diffuse tenderness over the GH jt which may extend to the trapezius and interscapular areas range of motion
○ loss of passive external rotation
○ other movements of the jt are reduced and residual movement may be attributed to thoracoscapular component

pain and stiffness may not allow you to carry a full range of physical examinations muscle strength / performance joint integrity / mobility special tests.

 

? infection / joint sepsis ( erythema , fever ) unreduced dislocation unexplained neurological features (e, g referred neck pain ) , wasting , sig sensory / motor deficits suspected malignancy ? tumour ? mass / swelling acute RC tear due to trauma ( h/o trauma , pain , weakness ) suspected inflammatory joint condition.

 

diagnosis is clinical ( imaging is complimentary ) no specific test alone provides a definitive confirmation of the diagnosis blood tests ( as CRP , ESR , HLA B27 ) are normal and can be measured to exclude other conditions test for diabetes / thyroid disorders- if clinically suspected plain XR may show osteopenia which may happen due to disuse in long standing cases ( disuse osteopenia )
○ request AP/ lateral views
○ plain XR plays little role in evaluation but helps in ruling out other conditions as tumours , AC / GH osteoarthritis ) high- resolution musculoskeletal ultrasonography ( thickening of the coracohumeral ligament , fluid accumulation around the long head of biceps tendon ) MRI / MRA – thickening of capsular and pericapsular tissues , contracted glenohumeral space.

 

Differentials -impingement syndrome calcific tendonitis septic arthritis posterior shoulder dislocation fracture malunion rotator cuff pathology gleno-humeral arthritis acromioclavicular joint dysfunction / arthritis cervical radiculopathy / spine pathology malignancy ( Pancoast tumour )

 

natural history is for ultimate resolution ( traditional thought – self limiting and benign condition with most cases recovering in 2 yrs ) no consensus on ideal treatment regimen treatment should be tailored to the individual can run a protracted course & symptoms may take 1 – 3 yrs to resolve disability may last over a period of 1 or more years , some may suffer a protracted course with full ROM not restored even after 4 yrs in primary care mainstay of treatment is 
○ pain control physiotherapy ( 6-12 weeks ) land mark guided steroid injection complications of AC include residual pain , stiffness and treatment related complications ( up to 40 % may experience persistent symptoms )

 

identification of disease stage may help in planning treatment aim of the treatment is to reduce pain , improve ROM , reduce the duration of symptoms and restoration of normal function for e,g in the the painful freezing phase we can offer pain control , reduction of inflammation and patient education
○ pain control can be via NSAIDs / opiates
○ physical therapies can be helpful therapeutic US , cryotherapy , TENS machine supervised therapeutic exercise ( via physiotherapy ) home exercise program intra-articular steroid injection physiotherapy likely to be more beneficial in the frozen or stiffness phase

 

failure to improve with 3 months of conservative primary care management severe symptoms / degree of stiffness causing significant functional compromise ( e,g severe night pain not releived by analgesia , inability to work or undertake daily activities ) diagnostic uncertainty.

 

manipulation under anaesthesia ( MUA )
○ can lead to improvement in shoulder function and ROM
○ involves tearing of the thickened inflammed capsule and contracted lig’s
○ complications may include humeral shaft fracture , glenoid fracture , RC tear shoulder dislocation and traction injury to nerve
○ it is not sure if MUA shortens the natural h/o the condition
 surgical release -arthroscopic capsular release ( ACR )
○ can be employed if MUA fails or some surgeons may advocate it without MUA
○ open surgical release
 distension arthrogram ( DA ) or hydrodilatation physiotherapy and steroid injections.

PATIENT INFORMATION

Oxford shoulder and elbow clinic has produced an 8 page printable document outlining the main aspects of AC for the patient -very useful with exercises https://www.ouh.nhs.uk/shoulderandelbow/information/documents/a4frozenshoulderappendix3.pdf

A good coverage from BUPA including exercise videos https://www.bupa.co.uk/health-information/muscles-bones-joints/frozen-shoulder

Frozen shoulder exercise videos NHS Scotland https://www.nhsaaa.net/allied-health-professionals-ahps/musculoskeletal-service/frozen-shoulder-exercises/

 

REFERENCES

  1. Tzeng, Chung-Yuh MD, PhDa,b; Chiang, Hsiu-Yin PhDc; Huang, Chun-Che PhDd,e; Lin, Wei-Szu MSce; Hsiao, Tzu-Hung PhDe,f; Lin, Ching-Heng PhDe,f,g,h,∗ The impact of pre-existing shoulder diseases and traumatic injuries of the shoulder on adhesive capsulitis in adult population, Medicine: September 2019 – Volume 98 – Issue 39 – p e17204 doi: 10.1097/MD.0000000000017204
  2. South & West Devon Formulary and referral Shoulder – Frozen shoulder Shoulder – Frozen shoulder (devonformularyguidance.nhs.uk)
  3. Midnottspathways Frozen shoulder msk_shoulder-pathway-2019.pdf (midnottspathways.nhs.uk)
  4. BESS/BOA Patient Care Pathways Frozen Shoulder Amar Rangan, Lorna Goodchild, Jo Gibson, Peter Brownson, Michael Thomas, Jonathan Rees and Ro Kulkarni *frozen shoulder.pdf (boa.ac.uk)
  5. Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care Satya Pal Sharma1*, Anders Bærheim1
    , Rolf Moe-Nilssen2 and Alice Kvåle2,3 *Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care (biomedcentral.com)
  6. Dias, Richard et al. “Frozen shoulder.” BMJ (Clinical research ed.) vol. 331,7530 (2005): 1453-6. doi:10.1136/bmj.331.7530.1453
  7. Mezian K, Coffey R, Chang KV. Frozen Shoulder. [Updated 2021 Sep 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482162/
  8. Le, Hai V et al. “Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments.” Shoulder & elbow vol. 9,2 (2017): 75-84. doi:10.1177/1758573216676786
  9. St Angelo JM, Fabiano SE. Adhesive Capsulitis. [Updated 2021 May 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532955/
  10. Cho, Chul-Hyun et al. “Treatment Strategy for Frozen Shoulder.” Clinics in orthopedic surgery vol. 11,3 (2019): 249-257. doi:10.4055/cios.2019.11.3.249
  11. Sarasua, S.M., Floyd, S., Bridges, W.C. et al. The epidemiology and etiology of adhesive capsulitis in the U.S. Medicare population. BMC Musculoskelet Disord 22, 828 (2021). https://doi.org/10.1186/s12891-021-04704-9
  12. Robinson C. M.Seah K. T. MChee Y. H.Hindle P., and Murray I. R. The Journal of Bone and Joint Surgery. British volume 2012 94-B:11-9

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