What is Frozen shoulder?
Frozen shoulder is a common shoulder disease and its incidence is estimated to be 2–5% in the population. It is rare in children and peaks between 40 and 70 years of age, in particular the highest incidence in woman is between 50-55 years and in man between 55-60 years. Patients with diabetes and distyroidism are predisposed and those who experience it on one shoulder are more likely of developing the condition on the contralateral side. Women are more often affected than men, but there is no known genetic or racial predilection.
The aetiology and pathogenesis of primary frozen shoulder are not known; it results from contraction of the glenohumeral joint capsule and adherence to the humeral head. Zuckerman et al formulated a descriptive consensus definition for frozen shoulder “a condition characterized by functional restriction of both active and passive shoulder motion for which radiographs of the glenohumeral joint are essentially unremarkable”.
Frozen shoulder has a high impact on the quality of life, due to the severe pain and functional disability; loss of passive external rotation (ER) is the most characteristic finding at physical examination.
Causes & Symptoms
There often is no identifiable cause or trigger. The pain is often described as a poorly localized, deep ache and can radiate to the biceps area.
It is characterized by three phases: the freezing phase (acute pain and gradual loss of motion of the glenohumeral joint in all directions), frozen phase (severe stiffness and improvement of the pain) and the thawing phase (range of motion (ROM) gradually returns to normal). Although frozen shoulder is often considered to be self- limiting, full resolution of symptoms does not always occur. Only 59% of the patients had a near normal shoulder after 4 years. However, persistent symptoms are commonly mild. No therapeutic intervention is currently universally accepted as most effective for restoring motion and diminishing pain in patients with frozen shoulder.
The diagnosis of frozen shoulder is usually clinical. The glenohumeral joint capsule is comprised of soft tissue and is therefore not visible on plain radiography. However, radiography can rule out other conditions and detect concomitant pathology; it is also useful to assess for Pancoast tumors, advanced glenohumeral arthritis, pathologic fracture, avascular necrosis, calcific rotator cuff and biceps tendinopathy. Magnetic resonance imaging (MRI) is not diagnostic for adhesive capsulitis, but can be helpful in identifying other conditions, such as rotator cuff tendinopathy and subacromial bursitis; capsular thickening can sometimes be observed.
Frozen shoulder must be differentiated by secondary adhesive capsulitis which gives similar clinical presentation but it is caused by another etiological entity (trauma, subacromial bursitis, rotator cuff tendinopathy/tear, autoimmune diseases, neoplasm, cervical disk degeneration).
Watchful waiting or ‘supervised neglect’ involves explaining the condition to the patient, educate and advice about mobilisation within pain limits and use of pain relief.
Oral steroids are given to relieve pain and stiffness in patients with frozen shoulder. However, randomised control trials (RCT) comparing oral steroids and placebo or no treatment, showed no differences in the pain and recovery of the ROM in patients affected from frozen shoulder.[5–7]
Intra-articular corticosteroid injections are a commonly used intervention in treating shoulder pain in general. A Cochrane review focussed on this treatment reported on the effectiveness of corticosteroid injections in treating shoulder pain, including 13 RCTs (n=656) on frozen shoulder. The majority of the RCT showed good results after intra-articular steroid injection if compared with a placebo group. Because the glenohumeral joint lies deep within the shoulder, correct technique and placement can be challenging. Ultrasound guidance may be helpful to ensure correct placement. There is evidence to support the use of up to three injections over the course of four months without significant risk of complications in shoulder disease but most of the time in a frozen shoulder if the injection works (success rate is about 25-30% of cases) a single injection is enough to stop and trigger the resolution of this disease.
Steroid injection versus physiotherapy
Steroid injection was reported to be more effective than physiotherapy both on pain and ROM at 4 months.[10–12] On ROM, the combination of steroid injection with physiotherapy was more effective than physiotherapy or steroid injection alone (p<0.05).
Rehabilitation, as a home exercise program or physical therapy, has traditionally been a cornerstone of treatment for frozen shoulder. However, there are no high-level studies that clearly demonstrate benefit over observation or medical therapy alone. Aggressive physical therapy can exacerbate pain and diminish adherence to the treatment plan; therefore, caution should be used in patients who have a high degree of pain and stiffness. Initial therapy typically includes gentle ROM exercises, although evidence is lacking (figure 1). In our experience, proprioceptive neuromuscular facilitation (PNF) which is a form of static stretching that combines passive with isometric stretching, delivers the best results in the treatment of frozen shoulder. There are several different PNF techniques, although the most common technique (hold-relax) is performed when a muscle is statically stretched, then isometrically contracted, and finally statically stretched again. The stretching is performed in 3 cycles, minimum of 3 times a day and focuses on the anterior (figure 2) and posterior (figure 3) capsule. Gentle mobilization of the shoulder in a swimming pool or formal hydrotherapy might help to reduce muscle contractures and regular selfstretching can help to maintain partially the range of motion.
Other therapies, such as ultrasound, massage, iontophoresis, and phonophoresis, have not been proven effective for frozen shoulder.
Acupuncture is postulated to work by releasing endogenous opioids in the body that relieve pain, by overriding pain signals in the nerves, or by allowing energy or blood to flow freely through the body. Several RCT showed good results in reducing shoulder pain, those specifically focused on frozen shoulder showed mixed results, however, a high quality RCT showed good results of acupuncture combined with physical therapy if compared with physiotherapy alone.
Arthrographic distension (hydrodilatation) of the glenohumeral joint is thought to disrupt adhesions that might be restricting the shoulder ROM. It can be achieved with combinations of saline, local anaesthetic, steroid, contrast medium and air. Authors reported to have injected between 20 and 80 ml fluid in the glenohumeral joint until rupture of the capsule occurred.
Systematic Cochrane reviews[15, 16] reported good short term results after hydrodilatation with complications confined to pain during or after the procedure. However, it is difficult to draw definitive conclusions as several techniques can be used including the use of steroids and post treatment physical therapy. Furthermore, the long term benefits are uncertain and recurrence of the symptoms have been reported. [15–17] Finally it seems more effective in recovering the forward flexion and abduction more than rotational movements that are most severely affected by frozen shoulder.
Patients with adhesive capsulitis who have little or no improvement after six to 12 weeks of conservative treatment and who cannot tolerate their symptoms should be referred to an orthopedic surgeon. Those who improve but then plateau at an unacceptable level after longer courses of nonsurgical therapy can also be considered for surgical referral.
Surgical options for adhesive capsulitis include joint manipulation under anesthesia and arthroscopic capsular release.
Manipulation under anesthesia (MUA)
MUA is believed to be the most widely used non-conservative treatment option for these refractory cases. With MUA, the tight shoulder joint capsule is stretched and torn (figure 4) with manipulation (under general anesthesia (GA)). It is a time efficient procedure and relatively easy to perform, resulting in rapid restoration of the ROM. The literature reports that patients’ satisfaction is >80% at 3 months and 94% at 6 months follow up. It can be associated with a risk of iatrogenic proximal humeral fracture, glenohumeral dislocation, and rotator cuff tearing, however the overall complication rate in the literature is reported to be <1%. The Codman’s Paradox (figure 5) was shown to be a safe technique to perform a safe MUA, minimizing the risks related to the procedure.
More recently this technique has been associated with Hydrodilatation, the dilatation of the joint reduce the risk of complications during MUA and often speed up the recovery process for rotational movement.
Arthroscopic capsular release (ACR)
Surgical release of the capsule has proved to be beneficial in patients with persistent or severe frozen shoulder.[20, 21] Good pain relief and functional recovery is achieved and complications are minimal. The procedure is performed under GA and regional block; an arthroscopic radiofrequency device is used to release the adhesions and the capsule of the glenohumeral joint. A 270-360 degrees release is performed and restoration of full ROM is achieved (figure 6). Once the patient recovers from the GA, he/she is invited to passively stretch the shoulder while the regional blocks controls the pain. Physiotherapy is started as soon as possible (24-72h post intervention) to maintain the movement of the shoulder and reduce the risk of recurrence. Painkillers are prescribed to help the patient during passive exercises.
Frozen shoulder is a long benign disease of the Shoulder that in the first phase can impair the use of the arm and can disrupt the quality of life of patients because of severe and unremitting pain with associated with sleep disturbance.
If recognized early can be effectively treated with intrarticular steroid injections, better done under USS guidance, or in case of scarce response might benefit from a combination of Hydrodilatation and manipulation under anesthesia which is a minimally invasive treatment or in severe cases might benefit from an arthroscopic capsular release which a very effective and successful technique.
Figure 1. Standard stretching exercises (passive stretching)
Figure 2. PFN anterior capsule stretching
Figure 3. PFN posterior capsule stretching
Figure 4. Arthroscopic view of torn capsule after MUA
Figure 5 Demonstration of the Codman paradox. Prior to any movement, the arms are on the sides with the palms towards the thighs, thumbs pointing forwards. Full forward flexion is performed. From full elevation, bringing the arms down on the sides (without performing any rotation movement). The palms are facing outwards, thumbs pointing to the back. An apparent 180 degrees of external rotation occurred in the shoulder
Figure 6 Arthroscopic view of severe synovitis in the anterior aspect of the shoulder (rotator interval/anterior capsule)
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- Kivimäki J, Pohjolainen T, Malmivaara A, Kannisto M, Guillaume J, Seitsalo S, Nissinen M (2007) Manipulation under anesthesia with home exercises versus home exercises alone in the treatment of frozen shoulder: A randomized, controlled trial with 125 patients. J Shoulder Elb Surg. doi: 10.1016/j.jse.2007.02.125
- Zuckerman JD, Rokito A (2011) Frozen shoulder: A consensus definition. J Shoulder Elb Surg. doi: 10.1016/j.jse.2010.07.008
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- Calis M, Demir H, Ulker S, Kirnap M, Duygulu F, Calis HT (2006) Is intraarticular sodium hyaluronate injection an alternative treatment in patients with adhesive capsulitis? Rheumatol Int. doi: 10.1007/s00296-005-0022-2
- Carette S, Moffet H, Tardif J, et al (2003) Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: A placebo-controlled trial. Arthritis Rheum. doi: 10.1002/art.10954
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