Definition
Frozen shoulder is a painful contracture of the glenohumeral capsule causing restriction of both active and passive movement, particularly external rotation.
Adhesive capsulitis is a painful condition characterised by progressive restriction of both active and passive glenohumeral movement. External rotation is typically particularly restricted.
It may be:
- primary/idiopathic
- secondary to diabetes, thyroid disease, trauma, surgery or prolonged immobilisation
Types
- primary: no clear initiating cause
- secondary: associated with factors such as diabetes, thyroid disease, trauma, surgery or prolonged immobilisation
Clinical phases
The course is variable, but can be thought of as:
- painful inflammatory phase
- stiff phase
- gradual recovery phase
Symptoms do not always follow a neat timetable.
The classic description includes:
- painful/freezing phase
- stiff/frozen phase
- recovery/thawing phase
The course is variable and symptoms may persist longer than simplistic stage descriptions suggest.
Examination
Typical findings:
- globally restricted passive movement
- external rotation often most limited
- pain at end range
- strength difficult to assess fully because of pain and stiffness
The important finding is global passive restriction, not simply pain on elevation.
Compare:
- external rotation with the arm by the side
- elevation
- internal rotation
Exclude:
- glenohumeral arthritis
- cuff tear with pseudoparesis
- cervical pathology
- infection
- tumour in atypical cases
Plain radiographs should usually be obtained to exclude structural joint disease.
Investigations
Plain radiographs are used to exclude glenohumeral arthritis and other bony causes of stiffness. Ultrasound or MRI is reserved for diagnostic uncertainty or suspected associated pathology.
Treatment
Early management
- explanation and reassurance
- analgesia
- gentle range-of-motion work within tolerance
- intra-articular corticosteroid injection can be useful, particularly in the painful phase
Persistent stiffness
Options include:
- supervised physiotherapy
- image-guided hydrodilatation in selected patients
- manipulation under anaesthesia
- arthroscopic capsular release
Manipulation carries risks including fracture and soft-tissue injury, particularly in osteoporotic patients.
Important differential diagnoses
- glenohumeral osteoarthritis
- rotator-cuff tear with pain inhibition
- cervical radiculopathy
- occult fracture
- infection
- tumour
The key examination feature is restricted passive as well as active movement.
Pathology
Capsular inflammation and fibrosis lead to contracture, particularly involving the rotator interval and coracohumeral ligament region, with reduced capsular volume.
Non-operative treatment
Most patients are treated initially with:
- education
- analgesia
- activity within tolerance
- physiotherapy appropriate to irritability
- intra-articular corticosteroid injection, particularly when pain is prominent
Overly aggressive stretching during a highly painful phase can aggravate symptoms.
Escalation
For persistent substantial stiffness despite an adequate non-operative period, options may include:
- hydrodilatation
- manipulation under anaesthesia
- arthroscopic capsular release
Manipulation carries risks including fracture, cuff injury and neurological injury, particularly in vulnerable patients.
Arthroscopic release permits controlled division of contracted capsule but requires careful protection of nearby neurovascular structures, especially inferiorly.
Diabetes
Patients with diabetes have a higher prevalence of frozen shoulder and may have more persistent or recurrent symptoms.
FRCS synthesis
A strong answer emphasises:
- restriction of passive as well as active movement
- exclusion of arthritis on radiographs
- stepwise treatment
- cautious escalation rather than immediate surgery