Frozen Shoulder

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Search Strategy

To search for information about adhesive capsulitis, medical databases, such as Pubmed and PEDro, were used. Keywords I used to find information are adhesive capsulitis, frozen shoulder, treatment AND adhesive capsulitis, exercises AND adhesive capsulitis. To improve the strategy I used the limits on Pubmed: 5 years (published in the last), English (languages), humans (species). The amount of articles is 303.

Definition/Description

Adhesive capsulitis, or frozen shoulder, is a condtion in which the capsule of the glenohumeral joint is inflamed. It is characterized by a painful, gradual loss of both active and passive glenohumeral motion, resulting from progressive fibrosis and contracture of the glenohumeral joint capsule.   Contracture is defined as shortening of connective tissue (ligaments, tendons, and cartilage) and caused by excessive arthrofibrosis, immobilization, inactivation and adhesions. 

Adhesive capsulitis is described as being either primary or secondary. Primary, or idiopathic, adhesive capsulitis is due to an unknown cause, whereas secondary adhesive capsulitis results from a known cause or surgical event.

Clinically Relevant Anatomy

Contracture of the rotator cuff interval (RCI) is prevalent. The RCI forms the triangular-shaped tissue between the anterior supraspinatus tendon edge and upper subscapularis border, and includes the superior glenohumeral ligament and the coracohumeral ligament.

Significant subacromial scarring, loss of the subscapular recess, and inflammation of the long head of the biceps tendon and its synovial sheath is noticed in patients with frozen shoulder.

Epidemiology /Etiology

Adhesive capsulitis occurs in 2% to 5% of the population. The majority of patients are female, and especially between the ages of 40 to 60 years.  The non-dominant hand is more frequently involved, and about 20% to 30% of those affected will develop the condition in the opposite shoulder. 

The causes remain unclear. Twenty percent to 30% of patients will report a history of minor trauma to the shoulder, but there is no further evidence that this is a posttraumatic condition. Others develop this condition due to an unknown cause.

The development of adhesive capsulitis has been associated with:

- diabetes mellitus

- thyroid dysfunction

- Dupuytrens contractures

- autoimmune disease

- the treatment of breast cancer.

Patients with cerebrovascular accident or myocardial infarction have been reported to be at increased risk. In general, it’s more common in those with sedentary vocations than in manual laborers.

Characteristics/Clinical Presentation

Idiopathic adhesive capsulitis is characterized by multiple stages.

Many scientists describe 3 clinical phases:

- the painful stage

-  the frozen or adhesive stage 

- the thawing or regressive stage. 

The difference between phase 1 and 2 is not very explicit, but an intra-articular anesthetic injection can be used to discriminate between these stages.

Stage 1 is characterized by a gradual onset of pain typically referred to the deltoid insertion. Pain is the main initial complaint. It is usually achy at rest and sharper with movement. Patients often report pain at night and an inability to sleep on the affected side. During examination, an empty end feel at the extremes of motion can be observed. Forward flexion, abduction and rotation may worsen the pain. Patients can also indicate limited motion. In this stage, duration of symptoms is generally less than 3 months.  Motion can be fully restored, when pain is relieved by an intra-articular anesthetic injection.

Stage 2 represents a combination of acute synovitis and progressive capsular contracture. Pain persists and may be more severe. Motion is restricted in forward flexion, abduction, and internal and external rotation. Duration of symptoms can range from 3 to 9 months. The limitation cannot be fully restored.

In stage 3, the frozen stage, the main complaint is significant stiffness with decreased range of motion. Pain may still be present at the end range of motion and occasionally at night. Physical examination reveals a sense of mechanical block or tethering at the ends of motion. Symptoms have typically been present for 9 to 15 months at this point.

Stage 4, the chronic stage, has also been termed the thawing stage. Pain is minimal, and a gradual improvement in motion can occur. This stage typically lasts 15 to 24 months.

Also it is not unusual for a patient to develop a frozen shoulder on the opposite side after the original condition has improved.

Differential Diagnosis

Rotator cuff tendinosis, subacromial bursitis (impigment syndrome), rotator cuff tear, cervical radiculopathy, any fracture or dislocation of the shoulder, arthritis, thoracic outlet syndrome. 

Magnetic resonance imaging (MRI) helps with the differential diagnosis by identifying soft tissue abnormalities of the rotator cuff and labrum.

Diagnostic Procedures

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Outcome Measures

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Examination

To differentiate between adhesive capsulitis and other pathologies multiple shoulder-specific outcome measures are available, such as:

- the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH)

- Simple Shoulder Test (SST)

- Penn Shoulder Score

- American Shoulder and Elbow Surgeons (ASES) score

- the Constant-Murley score.

Also a full upper-quarter examination is performed to rule out cervical spine and neurological pathologies.

With frozen shoulder, the examination of the shoulder typically reveals significant limitation of both active and passive elevation, usually less than 120°. These motion limitations are stage dependent. A greater than 50% reduction in passive external rotation or less than 30° of external rotation, when measured with the arm at the side, is also a common finding.

To explore muscle function associated with shoulder movements, muscle strength test examination may be used. An isokinetic machine is proved to be reliable and is frequently used in clinics to investigate muscle strength.

Medical Management

• Intra-articular steroid injections
• Manipulation under anesthesia (MUA)
• Suprascapular nerve block (SSNB)
• Hydrodalition
• Arthroscopy
• Open capsular release
  

Physical Therapy Management

There are many types of treatment used to manage the frozen shoulder, but there is no consensus on how best to manage patients with this painful condition. Physical therapy is the most consistently prescribed treatment to prevent capsular contraction and to improve motion in the latter stages of this disease. However there is no evidence found that physiotherapy alone is of benefit in adhesive capsulitis.

Traditionally, physiotherapists treat adhesive capsulitis with a variety of interventions including mobilizations, stretching, strengthening and home exercises, to restore range of movement and function. Steroid injections are used to reduce the initial pain. In short term, they seem to be more beneficial than physiotherapy. The effect appears to be the most significant around 6 to 7 weeks. Thus the combination of physical therapy and steroid injections can provide a more effective and streamlined care package for patients. A ‘Wait-and-see policy’ is certainly not a good treatment for patients with a frozen shoulder. Both physiotherapy as corticosteroid injections alone, are more effective than no treatment at all.

For patients in stage 1, the main goal of therapy is to decrease the pain. Gentle stretching and active motion within the pain-free range appear to be sufficient. Also pendulum exercises can be applied. Mobilizations of the shoulder joint will be performed by the physiotherapist. All activities that provoke pain should be avoided. Therapeutic modalities, such as ice, heat, massage, ultrasound, acupuncture and electrotherapy, can be employed for muscle relaxation and to relieve the pain.

In stage 2, patients have the additional goal of minimizing capsular adhesions and restrictions of motion. Griggs, et al. revealed a significant benefit from participating in a "Four-direction shoulder-stretching exercise program" in stage 2 idiopathic adhesive capsulitis. 90% of the patients gained significant increases in ROM of external and internal rotation, flexion and abduction in the first few months and maintained ROM through this daily program. The use of low-load prolonged-duration stretch, combined with the therapeutic principle of increased time at end range, allows the patient to reduce contracture by achieving permanent elongation of connective tissue.

During stage 3, aggressive stretching should be the mainstay of therapy. Active warm-up to enhance soft tissue circulation is performed. Prolonged, low-load stretching is more effective than brief, high-load stretching. Stretches may be held from 1 to 5 seconds at the relatively pain-free range, 2 to 3 times a day. Tissue stress is progressed by increasing stretch frequency and duration, while keeping the intensity in tolerable limits. The patient may be asked to hold the stretch for longer periods and increase the number of sessions per day. A consistent home exercise program is important, because daily exercise is effective in relieving symptoms. Use of the Shoulder Dynasplint System (SDS) showed an effective adjunct "home therapy" for adhesive capsulitis. 80 to 90 hours of endrange stretching as home therapy in addition to physical therapy is considered to be responsible for the greatest change in active external rotation. 

Specific therapy for stage 4 does not greatly differ from stage 3. Further cuff strengthening including conditioning is initiated as motion improves.

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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