Frozen Shoulder (Adhesive Capsulitis) — A Patients Guide

Evidence-based conservative and specialist treatment pathways for Adhesive Capsulitis (aka Frozen Shoulder)

This blogpost is a ‘guide’ only, should not be taken as medical advice and does not replace the recommendations from a registered and regulated healthcare professional who has conducted a comprehensive assessment.

Frozen Shoulder (FS), known in the medical community as Adhesive Capsulitis, is a painful shoulder condition where the Glenohumeral Joint (shoulder) capsule becomes thick and inflamed, which can lead to moderate to severe pain and severe restriction of range of movement (ROM), particularly affecting External Rotation [1], significantly day-to-day upper limb function and also sleep.

External rotation is very useful for reaching tasks.

Who Gets Frozen Shoulder?

FS cam affect up to 20–25% of the population[2], it can occur in those aged 30–65 [3], however it usually prsents in those aged 40–60 [4]. It occurs in females 70% more than males [5] with the peak age of 50 appearing to coincide with Menopause.

Although the condition can occur spontaneously there are risk factors reported to increase the chance of developing FS. Patients who have diabetes are five times more likely to get FS [1]. There is also increase risk in those who have had recent surgery or other trauma, hyperthyroidism [6], dys-/hyper-lipidaemia [7] , recent breast cancer treatment [8] and there’s even a suggestion that a genetic predisposition may exist [9].

One of our experienced local Radiologists thinks that Shoulder Surgeons who perform shoulder surgery in at-risk FS cohorts should consider injecting the joint at the end of the operation — which sounds like a good idea. However, that could increase infection risk, but to me… that risk can’t be much greater than the operation itself?

One study found that of the FS’s that were spontaneous (idiopathic), post-trauma relate or diabetes-related there was a presentation ratio of roughly 7:2:1 (spontaneous:post-trauma:diabetes-related). Women dominated the spontaneous presentations, whereas men dominated the diabetic related presentations [2].

What is Frozen Shoulder?

Up until recently FS has classicalyl been described as having 3 phases:

1. Freezing — increasing pain, decreasing movement
2. Frozen — pain stabilising, loss of movement
3. Thawing — less pain, increasing movement

However, patients experiences are so varied and the pain-experience hasn’t been validated in the three-phase model, so it’s much more accurate to describe the condition as having two vague phases:

Stage 1. More Painful than Stiff — when there is an increase in number and size of blood vessels, leading to inflammation of the capsule [10]. One patient in this phase best described it as “it’s just an asshole”.

Stage 2. More Stiff than Painful — when scar tissue and adhesions form on the capsule [10] which significantly reduces the size of the shoulder (glenohumeral) joint capsule from 28–35ml to about 5–10ml [11]. Roughly the same volume difference of a tennis ball to a golf ball, this leads to the significant loss of range of movement.

The volume of the Glenohumeral Joint Capsule reduces in size the equivalent of a tennis ball into a golf ball.

Self-Limiting/”Resolves with Time”

Traditionally it has been said FS will take 6–18 months to self-resolve, however it is now suggested FS can take anywhere from 1–3 years to resolve [12], and not fully resolve [13], some will still experience symptoms (mostly loss of range of movement) for up to 6 years [14].

A ‘wait and see’ approach (amusing the patient whilst nature cures the disease) probably isn’t appropriate given 20–50% of patients end up with a permanent loss of range of movement (ROM), the degree of the loss of ROM often depends on the severity of the condition.

Unfortunately 40–50% of patients then may go on to develop FS in the other shoulder [15], my experience is that those who get it younger (<50) are more susceptible to get it the second time in the other shoulder. However it seems that patients don’t get FS again in the same shoulder.

See a Registered and Regulated Healthcare Professional

It’s very important that patients with Shoulder pain that could be FS see a registered and regulated Healthcare Professional (GP, Physiotherapist, Sports and Exercise Physician, Orthopaedic Specialist) who has the time (30mins or more) to do a thorough physical assessment is to rule out and reassure the patient that they don’t have any serious conditions that mimic Frozen Shoulder.

Tumours, Infections (especially if the patient has had recent surgery), Calcific Tendinosis and several other conditions can all have a gradual onset in the 40–60 year old shoulder causing a loss of range of motion with accompanying pain and these must be ruled out and you can only get that service from a Regulated and Registered Healthcare Professional.

Conservative Management

For FS there are many available management pathways but no known effective treatments that will to shorten the duration of the condition in the long-term [12, 16, 17].

However, Physiotherapy and Exercise Physiology can help during Frozen Shoulder:

• Provide short-term pain-relief (this may improve to medium-term when combined with other interventions such as corticosteroid injections. outcomes [16])
• Maintain strength of the shoulder, neck and trunk
• Reduce further loss of range of movement
• Improve self-efficacy and mental health during FS

We can also help after Frozen Shoulder has subsided:

• Restore strength of shoulder, neck and trunk
• Reduce the permanent loss of range of movement after FS
• Offer ongoing resistance training and exercise prescription with our EP team as part of healthy ageing and to reduce future injuries.

There are many conservative management options available for FS patients, both Passive (manual therapies such as massage, mobilisations, stretching etc.) and Active (exercise based, such as resistance training and hydrotherapy).

I am fortunate to work with a amazing team of Exercise Physiologists to help me deliver tailored long-term active management programs for my FS patients.

As a Physiotherapist, I will trial Passive treatments (manual therapies such as massage, stretching and mobilisation etc) for 2–3 sessions however if I don’t see any significant clinical changes (ROM and strength) I will recommend the patient see my Exercise Physiologist (EP) colleagues for more long-term and cost-effective options. The EPs can tailor a program to every patient that will help with pain relief, maintain strength, reduce further loss of range of movement during FS.

If you are a Physio or EP reading this an are looking for ideas on management of FS, check out this great blog by Tony Comella at E3 Rehab: https://e3rehab.com/blog/frozenshoulder/

Specialist Management

As with conservative options, there are no surgical or specialist interventions that will shorten the duration of FS. Although some interventions have evidence for improving pain in the short-medium term. However all of the below treatments come with risks attached to it (as with any injection or surgical procedure).

Including:

• Hydrocortisone injection into the joint — combined with Physiotherapy good short and medium term outcomes. [16]
• Hydro-dilatation/distension — increasing the size of the capsule with a high-volume injection of saline and hydrocortisone — significant reduction in pain, but only short-term. [18]
• ·MUA (Manipulation under anaesthetic) — no difference to Physiotherapy on long-term outcomes [19]

· Surgery — Capsular Release — No difference to Physiotherapy on long-term outcomes [19]

The only intervention that I have recently heard of via a Podcast that shows any signs of reducing long-term prognosis (the course of the disease) is a cortisone injection into the joint ifFS is caught in the first 30days of its presentation….. which is extremely unlikely as the average time from onset of shoulder pain to diagnosis of FS is 3 months (at best, in my experience). As of Feb 2023, this is from an unpublished longitudinal study by Dr Jo Hannafin (recently retired) so I’m keeping my eyes peeled for that one.

Coming to terms with the long-term nature of FS

Suggesting a patient has Frozen Shoulder is one of the most difficult tasks for me as a Clinician. Telling someone that I am unable to help make their shoulder better sooner and they’re going to have this condition for 1.5–3 (possibly up to 6) years is heartbreaking.

Patients are often blindsided by the diagnosis and usually can’t believe it, and no doubt will probably want to get a second or third opinion. Often, they experience a period of Grieving with mixed periods of denial, anger (usually at whoever gave them the diagnosis… sometimes me), depression and eventually acceptance.

Theory on the left, Reality on the right

To assist the Patient through this period I recommend the following pathway after I diagnose FS:

1. If the patient hasn’t yet them yet, get a referral from their GP for:

• An Xray to rule out nasties that mimic Frozen Shoulder (eg: calcific tendinopathy, fractures, tumours, infections)
• An Ultrasound (with “+/- HCLA” on the referral) just in case there is a bursitis mimicking Frozen Shoulder. The HCLA is a request for a Hydrocortisone + Local Anaesthetic injection if a Bursitis is thought to be present at the time of the ultrasound scan.

2. See a Shoulder Specialist/Orthopaedic Surgeon for a second opinion +/- MR imaging.

Once the above has been completed and imaging has ruled out other conditions that look-like-but-are-not Frozen Shoulder, patients are then usually able to better process the diagnosis, accept it sooner and move forward with an evidence-based management pathway of their choice. However, some patients may opt to go on an alternative treatment journey which is fine, as long as they find something that helps them during the course of Frozen Shoulder, everyone is different.

Summary

Frozen Shoulder (Adhesive Capsulitis) is a long-term condition causing pain and stiffness in the Shoulder which can take anywhere from 1.5–3 years (up to 6) to dissipate. Although there is no known treatment that can shorten the course of the condition there are management pathways that can reduce pain, the severity of FS, and help patients recover from FS with less long-term range of movement and strength impairments. These can be delivered by Physiotherapists and Exercise Physiologists. It is important patients are managed by regulated and registered healthcare professionals who can rule out ‘red flag’ conditions that mimic Frozen Shoulder and refer on when appropriate.

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References

1. Zreik, N.H., R.A. Malik, and C.P. Charalambous, Adhesive capsulitis of the shoulder and diabetes: a meta-analysis of prevalence. Muscles, ligaments and tendons journal, 2016. 6(1): p. 26.

2. Ando, A., et al., Identification of prognostic factors for the nonoperative treatment of stiff shoulder. International orthopaedics, 2013. 37: p. 859–864.

3. Bhargav, D. and G.A. Murrell, Basic science of adhesive capsulitis. Techniques in Shoulder & Elbow Surgery, 2011. 12(4): p. 126–129.

4. Boyle-Walker, K.L., et al., A profile of patients with adhesive capsulitis. Journal of hand therapy, 1997. 10(3): p. 222–228.

5. Sheridan, M.A. and J.A. Hannafin, Upper extremity: emphasis on frozen shoulder. Orthopedic Clinics, 2006. 37(4): p. 531–539.

6. Huang, S.-W., et al., Hyperthyroidism is a risk factor for developing adhesive capsulitis of the shoulder: a nationwide longitudinal population-based study. Scientific reports, 2014. 4(1): p. 4183.

7. Wang, J.-Y., et al., Hyperlipidemia is a risk factor of adhesive capsulitis: real-world evidence using the Taiwanese National Health Insurance Research Database. Orthopaedic Journal of Sports Medicine, 2021. 9(4): p. 2325967120986808.

8. Yang, S., et al., Prevalence and risk factors of adhesive capsulitis of the shoulder after breast cancer treatment. Supportive Care in Cancer, 2017. 25: p. 1317–1322.

9. Prodromidis, A.D. and C.P. Charalambous, Is there a genetic predisposition to frozen shoulder?: a systematic review and meta-analysis. JBJS reviews, 2016. 4(2): p. e4.

10. Neviaser, A.S. and J.A. Hannafin, Adhesive capsulitis: a review of current treatment. The American journal of sports medicine, 2010. 38(11): p. 2346–2356.

11. Rizk, T.E. and R.S. Pinals. Frozen shoulder. in Seminars in arthritis and rheumatism. 1982. Elsevier.

12. Le, H.V., et al., Adhesive capsulitis of the shoulder: review of pathophysiology and current clinical treatments. Shoulder & elbow, 2017. 9(2): p. 75–84.

13. Wong, C., et al., Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy, 2017. 103(1): p. 40–47.

14. Hand, C., et al., Long-term outcome of frozen shoulder. Journal of shoulder and elbow surgery, 2008. 17(2): p. 231–236.

15. Manske, R.C. and D. Prohaska, Diagnosis and management of adhesive capsulitis. Current reviews in musculoskeletal medicine, 2008. 1: p. 180–189.

16. Challoumas, D., et al., Comparison of treatments for frozen shoulder: a systematic review and meta-analysis. JAMA network open, 2020. 3(12): p. e2029581-e2029581.

17. Uppal, H.S., J.P. Evans, and C. Smith, Frozen shoulder: a systematic review of therapeutic options. World journal of orthopedics, 2015. 6(2): p. 263.

18. Zhang, J., et al., Comparative efficacy and patient-specific moderating factors of nonsurgical treatment strategies for frozen shoulder: an updated systematic review and network meta-analysis. The American Journal of Sports Medicine, 2021. 49(6): p. 1669–1679.

19. Rangan, A., et al., Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial. The Lancet, 2020. 396(10256): p. 977–989.