Frozen Shoulder

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Clinically Relevant Anatomy

Adhesive capsulitis is also known as frozen shoulder.  It involves progressive stiffness of the glenohumeral joint.   Adhesive capsulitis can be primary when it is idiopathic or secondary when it results from a known cause or surgical event. 

Mechanism of Injury / Pathological Process

Adhesive capsulitis has been reported to affect 2-3% of the general population and up to 30% of people with type II diabetes.  It is more common in women aged 40-60.   While recurrence in the same shoulder is rare, contra-lateral shoulder involvement has been estimated between 20-30%.  Other identified risk factors include  cervical disk disease, iimmobilization of the shoulder, cardiovascular disease, pulmonary disease, hyperthyroidism, and autoimmune diseases. 

Clinical Presentation

Patients may report progressive difficulty with dressing, grooming, and performing overhead activities. Literature describes adhesive capsulitis occuring in three overlapping phases.  The first phase, the painful stage, involves painful shoulder motion and sleep being interrupted.  The second state, the frozen or adhesive stage,  is characterized by reduced pain and loss of joint motion.  During the third stage, the resolution or thawing stage, pain is resolved and motion is gradually returned.    Adhesive capsulitis is thought to be self-limiting with the average recovery taking 3 years, though some authors report 50% of patients have pain or stiffness at 7 years.

Diagnostic Procedures

Though there is no valid clinical diagnostic criteria for adhesive capsulitis, a recent study gathered the opinions of 70 experts in adhesive capsulitis. They came to the following conensus on characteristics of people with adhesive capsulitis.

• night pain
• increase pain with rapid or unguarded movement
• pain is aggravated by movement
• increased discomfort lying on affected side
• global loss of active and passive motion
• pain at end range in all directions
• generally age of onset is >35 years old. 

In addition, if radiographs are taken, they are typically normal. 

Outcome Measures

DASH (see Outcome Measures Database)

Management / Interventions

Research has shown that joint mobilization and exercise increases the likelihood of successful outcomes.  Passive range of motion improved with Matiland grade III or IV mobilizations and posteriorly directed Kaltenborn grade III mobilizations.  Two pairs of interventions:  iontophoresis and phonophoresis and ultrasound and massage, decreased the likelihood of significant improvement by 19-32%. 

Intraarticular corticosteroid injections are another treatment option.  Random, controlled studies show injections with an exercise program improved pain and function scores at 2 weeks, but no difference at 12 weeks.  Therefore, cotricosteroids help initially with pain and function during the first few weeks, but not in the long term. 

Baums et al analyzed 30 patient who had not improved with 6 months of conservative treatment.  Following arthroscopic release, patients demonstrated improved range of motion, functional scores, and decreased pain. 

Differential Diagnosis

Differenctial diagnoses include rotator cuff tear, rotator cuff impingment, OA. 

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