Frozen shoulder or adhesive capsulitis is defined by the of American Shoulder and Elbow Surgeons as “a condition of uncertain aetiology characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder” (1) The disorder is typically classified as either primary (no known cause) or secondary (a known cause is identified e.g. shoulder injury/trauma or surgery, self-imposed immobilisation or associated with diabetes). Diagnosis can be difficult due to the impact of both intrinsic and extrinsic factors that can result in pain and disability (2).
The incidence of adhesive capsulitis is estimated to be between 2% and 5% of the general population (3, 4). The disorder is typically more common in women aged between 40 and 60 years (4). Adhesive capsulitis may occur unilaterally or bilaterally and activities such as reaching behind the back or overhead tend to become difficult.
Clinical Signs & Symptoms
- Painful shoulder triggered by minimal or no trauma
- Most commonly occurs in patients between 40-65yrs of age
- More common in men
- Painful shoulder with limited ROM
- Strength usually normal but can appear diminished when patient is in pain.
- Loss of active and passive ROM
- More common in patients with diabetes, thyroid or cardiovascular issues.
Lab Tests and Imaging
- Lab test usually normal except in the case of an underlying pathology
- Radiographic evaluation should be done to rule out any possibility of other pathologic conditions eg rotator cuff tears.
- Characteristic findings of adhesive capsulitis are a thickened coracohumeral ligament and joint capsule when a MRI is ordered
Review of Evidence for Management
Adhesive capsulitis typically occurs as a three stage process Stage 1 is characterised by gradual onset of pain (and loss of external rotation may occur); Stage 2 is regarded as the freezing stage (involving synovitis and capsular contraction) with pain persisting and restrictions in motion extending to include internal and external rotation, abduction, and forward flexion; Stage 3 is regarded as the frozen stage with significant stiffness occurring whilst pain may occur at night and at end range of movement. Collagenous tissue has become dense and thickened with only a thin layer of synovium; Stage 4 is known as the chronic or thawing stage with minimal pain and gradual improvements in motion (2).
Treatment strategies for adhesive capsulitis are targeted towards improving ROM, decreasing pain, and improving function. A recent systematic review concluded that there is limited clinical evidence on the treatment of adhesive capsulitis and there is no consensus on the best management (5).
Methods include pharmacological therapy, manual therapy, and surgical interventions. Pharmacological methods are directed towards treating the synovitis and inflammation whilst manual therapy aims to prevent and release capsular contraction. Surgery may be directed towards either aim by removal of synovium to address inflammation and/or capsule release and manipulation to address restrictions.
Pharmacological methods include NSAIDs, oral corticosteroids and corticosteroid injections to decrease inflammation and reduce pain. Corticosteroid injections are often combined with mobility and stretching exercises. A limited systematic review found that corticosteroid injections had a greater effect in the short term (6-7 weeks) than physiotherapeutic interventions. It was however also noted that physiotherapy was more beneficial than no treatment (6).
Manual therapy includes joint mobilisation, stretching, and manipulation. It is generally accepted that a conservative approach using physical therapy and stretching is advisable (and cost-effective), yet there is limited evidence to support this. A Cochrane review found no evidence that physiotherapy alone was of benefit in treating adhesive capsulitis (7). Other reviews have also found a need for quality research into this area (5).
Sources:
- Zuckerman J, Cuomo F, Rokito S. Definition and classification of frozen shoulder: a consensus approach. J Shoulder Elbow Surg. 1994;3(1):S72.
- Neviaser AS, Hannafin JA. Adhesive Capsulitis: A Review of Current Treatment. The American Journal of Sports Medicine. 2010:0363546509348048.
- Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA. Current review of adhesive capsulitis. Journal of Shoulder and Elbow Surgery. 2011;20(3):502-14
- Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. Journal of Shoulder and Elbow Surgery. 2008;17(2):231-6.
- Maund E, Craig D, Suekarran S, Neilson AR, Wright K, Brealey S, et al. Management of frozen shoulder: A systematic review and cost-effectiveness analysis. Health Technology Assessment. 2012;16(11):i-xvi+1-243.
- Blanchard V, Barr S, Cerisola FL. The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review. Physiotherapy. 2010;96(2):95-107.
- Green S, Buchbinder R, Hetrick SE. Physiotherapy interventions for shoulder pain. Cochrane Database of Systematic Reviews. 2003(2).
