Frozen Shoulder

Aka: Frozen Shoulder, Shoulder Adhesive Capsulitis, Adhesive Capsulitis

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II. Definitions

  1. Adhesive Capsulitis (Frozen Shoulder)
    1. Shoulder Pain and limited range of motion stemming from disuse

III. Epidemiology

  1. Peak age 40 to 60 years old
  2. Women more commonly affected
  3. Prevalence: 2-5% of general U.S. population

IV. Risk Factors

  1. Chronic Shoulder Pain (results in disuse)
    1. Bicipital Tenosynovitis
    2. Rotator Cuff Tendinitis
    3. Shoulder Band Syndrome (Reflex Sympathetic Dystrophy)
  2. Comorbid conditions that predispose to Adhesive Capsulitis
    1. Diabetes Mellitus (RR 5)
    2. Thyroid Disease

V. Symptoms

  1. Gradual onset of Shoulder stiffness and decreased range of motion
  2. Pain onset after significant Shoulder Range of Motion lost
  3. Pain poorly localized over the rotator cuff region
  4. Dull ache Sensation
  5. Pain radiation into deltoid and biceps or anterior arm
  6. Provocative
    1. Pain interferes with sleep (unable to lie on Shoulder)
    2. Reaching overhead or behind the back

VI. Signs

  1. Inspection
    1. Patient holds arm protectively at side
    2. Arm does not swing with walking (more severe cases)
    3. Deltoid Muscle and Supraspinatus Muscle atrophy
  2. Palpation
    1. Generalized pain at rotator cuff and biceps tendon
    2. However, localized tenderness may suggest other diagnosis (or inciting cause)
  3. Limited range of motion
    1. Loss of both active and passive Shoulder Range of Motion (pathognomonic)
    2. Loss of motion in all planes (flexion, extension, abduction, rotation)
    3. Normal range of motion excludes Adhesive Capsulitis as a diagnosis
  4. Associated Findings: Reflex Sympathetic Dystrophy
    1. Hand Edema, coolness, and discoloration

VII. Course: Three phases

  1. Phase 1: Pain
    1. Insidious onset of pain
  2. Phase 2: Stiffness
  3. Phase 3: Recovery
    1. Chronic, near full recovery may take over 6 months to years
      1. Greatest improvements in pain and range of motion occur earlier
    2. Most regain near full motion of Shoulder within 1-2 years even without intervention
      1. However, chronic residual deficits in range of motion and function are common

VIII. Differential Diagnosis

  1. See Shoulder Pain
  2. Rotator Cuff Tear or Tendinopathy
  3. Subacromial Bursitis
  4. Glenohumeral Osteoarthritis
  5. Acromioclavicular Arthropathy
  6. Bicipital Tendonitis
  7. Cervical Radiculopathy
  8. Rheumatoid Arthritis (or other Autoimmune Condition)
  9. Neoplasm
    1. Consider in systemic symptoms (fever, weight loss, Night Sweats)

IX. Labs

  1. Not typically indicated
  2. Consider Diabetes Mellitus (Glucose, HgbA1c) and Thyroid disease (TSH) screening
  3. Consider in suspected autoimmune cause (e.g. Rheumatoid Arthritis)

X. Imaging

  1. Shoulder XRay
    1. Typically normal in Adhesive Capsulitis
    2. Evaluate differential diagnosis
      1. Posterior Shoulder Dislocation
      2. Glenohumeral Osteoarthritis
      3. Pathologic Fracture
      4. Avascular necrosis
      5. Calcific Rotator Cuff Tendinopathy
  2. MRI Shoulder
    1. Findings suggestive of Adhesive Capsulitis
      1. Coracohumeral ligament thickening
      2. Rotator interval subcoracoid fat infiltration
      3. Axillary recess thickening

XI. Management

  1. Conservative measures to relieve pain
    1. Relative rest
    2. Moist heat
    3. Sedation to assist sleep at night
    4. Analgesics
      1. NSAIDs
      2. Often requires Opioid Analgesics
  2. Physical Therapy and Physiotherapy (Start as soon as possible)
    1. See Shoulder Range of Motion Exercises
    2. Avoid aggressive mobilization as it may prolong the course
    3. Initially, home Exercises are performed hourly
    4. Jason (2015) Int J Physiother Res 3(6): 1318-25 [PubMed]
  3. Subacromial Corticosteroid Injection
    1. Indicated at 6 weeks for course refractory to conservative measures and physical therapy
    2. Benefits do not appear to be maintained in the longterm (however may allow for physical therapy)
    3. May improve pain and function in the first 3 to 6 months after injection
    4. Restart Shoulder Range of Motion Exercises at 1 week after injection
    5. Ryans (2005) Rheumatology 44:529-35 [PubMed]
  4. Oral Corticosteroid (not typically recommended)
    1. NSAIDS and Subacromial Corticosteroid Injection are preferred
      1. Oral Corticosteroids risk significant adverse effects
    2. Dosing
      1. Prednisone 20 mg orally daily for 3-4 weeks
    3. Efficacy
      1. Superior to physical therapy or Acetaminophen
      2. Improved function and decreased pain in the first 1-2 months
      3. Benefits are not maintained in the longterm
  5. Aspiration and Lavage (Barbotage)
    1. Performed under Ultrasound guidance
    2. Preanesthesize with 1% Lidocaine via a 27 gauge needle
    3. Large bore needle (16-18 gauge) placed within calcific deposits
      1. Lidocaine 1% mixed 1:1 with Normal Saline with 10 cc syringe (6-8 cc per syringe)
      2. Insert needle within calcific deposit and rotate needle bevel to create seal
      3. Pepper the calcific deposit, injecting the Lidocaine/saline
      4. Apply constant back pressure on plunger
      5. Calcium deposits will be withdrawn into plunger
    4. References
      1. Shapiro (2016) Advanced U/S Guided Injections, GCUS Musculoskeletal Ultrasound, 1/28/2016
      2. Gatt (2014) Arthroscopy 30(9):1166-72 +PMID: 24813322 [PubMed]
  6. Acupuncture
    1. Green (2005) Cochrane Database Syst Rev (2):CD005319 [PubMed]
    2. Schroder (2017) Pain Med 18(11): 2235-47 [PubMed]
  7. Surgical Intervention
    1. Indicated for intolerable symptoms at 6-12 weeks refractory to above measures
    2. Procedures
      1. Careful Shoulder manipulation under general Anesthesia
        1. Exercise caution in patients with Osteoporosis, Osteopenia or Glenohumeral Instability
        2. Risk of Proximal Humerus Fracture
        3. Glenohumeral Dislocation
        4. Rotator Cuff Tear
      2. Capsular release by Shoulder arthroscopy
        1. Hydrodilation (arthroscopic distention)
        2. Local Anesthetic injected at high pressure to distend and stretch the joint capsule
        3. Buchbinder (2004) Ann Rheum Dis 53(3): 302-9 [PubMed]
      3. Cervical Sympathetic Nerve blocks (used historically for refractory pain control)

XII. Prevention

  1. See Shoulder Range of Motion Exercises
  2. Maintain Shoulder Range of Motion at time of injury
    1. Start shoulder Pendulum Exercises and wall walking Exercises early following Shoulder Injury
  3. Avoid Shoulder immobilization if at all possible (especially if age >50 years old)
    1. If immobilization required, avoid immobilization >3-7 days

XIII. References

  1. Burbank (2008) Am Fam Physician 77:493-7 [PubMed]
  2. Challoumas (2020) JAMA Netw Open 3(12): e20299581 [PubMed]
  3. Ewald (2011) Am Fam Physician 83(4): 417-22 [PubMed]
  4. Griggs (2000) J Bone Joint Surg Am 82-A:1398-407 [PubMed]
  5. Naviaser (2011) J Am Acad Orthop Surg 19(9): 536-42 [PubMed]
  6. Ramirez (2019) Am Fam Physician 99(5): 297-300 [PubMed]

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