Adhesive capsulitis (Frozen Shoulder)

Background

  • Poorly understood condition that can be disabling
  • Features include thickening of the synovial capsule, adhesions within the subacromial or subdeltoid bursa, adhesions to the biceps tendon
  • Thought to have an incidence of 3-5% in the general population (one of the most common orthopaedic problems)
    • More common in patients with diabetes and thyroid disease; more common in women, average age 40-65 years
    • Usually unilateral

Classification/Aetiology

  • Primary (idiopathic)
    • Insidious onset and progression
  • Secondary (trauma- usually not directly but due to subsequent immobilisation)

Clinical Phases

  1. Freezing/painful stage
    • In general, patients don’t present in this phase as they think it will resolve spontaneously.  However, pain tends to progress and ROM becomes limited
    • Typically 3-9 months
    • Characterised by acute synovitis of the glenohumoral joint
  2. Frozen/Transitional stage
    • Shoulder pain may improve such that there is no pain but ROM tends to remain limiting but not worsening
      • Usually external rotation most limited, then flexion and internal rotation
    • Typically 4-12 months
  3. Thawing stage
    • ROM can improve and shoulder gradually returns to normal
    • Lasts anywhere from 12-42 months

Presentation

  • Ask about symptom onset (any incidents/injury/trauma etc)
    • Often non-dominant hand (as there can be a tendency not to use this at all after injury)
  • Ask if symptoms are worse at night (often are) and ask about activities of daily living
  • On examination, there is often reduced ROM in all directions.  Pain may be a limiting factor.
    • The shoulder may be tender to palpate

Investigations

  • Although diagnosis is clinical, X-rays and other imaging modalities (namely MRI) may exclude other pathology)

Management

  • Pain relief (Paracetamol and NSAIDs) with physiotherapy are usually most beneficial
    • Steroid injection may be helpful and a quick relief prior to physiotherapy
  • Surgery is rarely performed
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