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