Synonym: frozen shoulder

Frozen shoulder is one of the most common causes of intrinsic shoulder pain. It is a glenohumeral disorder and can occur in one shoulder or both shoulders simultaneously. Thickening and contraction of the glenohumeral joint capsule and formation of adhesions causes pain and loss of movement.¹

Frozen shoulder can occur:

• Spontaneously
• Following rotator cuff lesions/injury
• In conditions causing immobility, e.g. after a cerebrovascular accident or plaster immobilisation

An autoimmune mechanism has also been proposed.²

See separate articles Shoulder Pain and Shoulder Examination.

Epidemiology

• Most commonly it affects ages 40-65 years; median age is 50-55 years.³
• It is more common in women.
• It is more common in diabetics.³
• It is also associated with thyroid disease.⁴

Presentation

• Global deep joint pain of acute or chronic onset.
• Restriction of all shoulder movements, both active and passive.
• Unable to sleep on affected side.
• Restriction of activities of daily living due to impaired external rotation, e.g. driving, dressing.
• Tends to be 3 phases: painful 'freezing' (can last 2-9 months), stiffness 'frozen' phase (4-12 months), recovery 'thaw' phase (5-24 months).⁵

Investigations

• The diagnosis is clinical.
• X-rays are usually normal.
• Consider other causes of shoulder pain. Have you got the correct diagnosis?
• Blood tests and radiography should only be performed if red flag symptoms are present.³ For a list of these, refer to the shoulder pain article.

Management

• Aim to treat early. Ideally you want to prevent an episode of capsulitis becoming frozen shoulder.
• An holistic approach to treatment should be used considering psychological and psychosocial factors.
• Use analgesia - paracetamol as first-line with non-steroidal anti-inflammatory drugs (NSAIDs) second-line provided there are no contra-indications. Use of a transcutaneous electrical nerve stimulation (TENS) machine may also be helpful.
• Encourage early activity.
• Provide a written patient information leaflet on shoulder pain.
• Injection with corticosteroids may reduce pain in the early stages.⁷
• Oral steroids may provide short-term benefit in pain and function but benefit may not persist beyond 6 weeks.⁸ Furthermore, they are unlikely to be superior to intra-articular injections.⁹
• Physiotherapy may cause more pain.¹⁰ There is no evidence that physiotherapy alone is of benefit but it may be helpful when combined with corticosteroids.¹¹
• Acupuncture may be helpful in the short-term.¹²
• Some surgeons perform manipulation under anaesthetic and arthroscopic release of the adhesions if conservative treatment fails.

Complications

• Long-term pain and shoulder stiffness.

Prognosis

• Symptoms can persist for 18 months to 3 years or more.³
• Consider referral to secondary care if pain and significant disability are present for >6 months despite appropriate conservative management.³

Prevention

• Whatever the reason, avoid prolonged immobilisation, e.g. slings, plaster casts, during illness.

Document references

1. Woodward TW, Best TM; The painful shoulder: part II. Acute and chronic disorders. Am Fam Physician. 2000 Jun 1;61(11):3291-300. [abstract]
2. Bulgen DY, Binder A, Hazleman BL, Park JR. Immunological studies in frozen shoulder. J Rheumatol. 1982 Nov-Dec;9(6):893-8.
3. Mitchell C, Adebajo A, Hay E, et al; Shoulder pain: diagnosis and management in primary care. BMJ. 2005 Nov 12;331(7525):1124-8.
4. Pearsall AW; Adhesive Capsulitis. eMedicine. Aug 2008.
5. No authors listed; Need patients be stuck with frozen shoulder? Drug Ther Bull. 2000 Nov;38(11):86-8
6. Woodward TW, Best TM; The painful shoulder: part I. Clinical evaluation. Am Fam Physician. 2000 May 15;61(10):3079-88. [abstract]
7. Buchbinder R, Green S, Youd JM; Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev. 2003;(1):CD004016. [abstract]
8. Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD006189.
9. Lorbach O, Anagnostakos K, Scherf C, et al; Nonoperative management of adhesive capsulitis of the shoulder: oral cortisone J Shoulder Elbow Surg. 2010 Mar;19(2):172-9. Epub 2009 Oct 1. [abstract]
10. Green S, Buchbinder R, Hetrick S; Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;(2):CD004258. [abstract]
11. Carette S, Moffet H, Tardif J, Bessette L, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum. 2003 Mar;48(3):829-38.
12. Green S, Buchbinder R, Hetrick S; Acupuncture for shoulder pain. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD005319. [abstract]

Internet and further reading

• Adhesive Capsulitis, Wheeless' Textbook of Medicine.

Acknowledgements