Adhesive Capsulitis of the Shoulder

Synonym: Frozen Shoulder

Frozen shoulder is one of the commonest 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 cerebrovascular accident or plaster immobilisation

An autoimmune mechanism has also been proposed.²

Please refer to the separate article entitled 'Shoulder Pain' for details on history, examination and differential diagnosis.

• Most commonly affects ages 40-65 years; median age 50-55 years.³
• More common in women.
• More common in diabetics.³
• Also associated with thyroid disease.⁴

• 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 2-9months), stiffness 'frozen' phase (4-12 months), recovery 'thaw' phase (5-24 months).⁵

• 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.

• 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 NSAIDs second line provided no contraindications. 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
• Physiotherapy may cause more pain.⁹ There is no evidence that physiotherapy alone is of benefit but it may be helpful when combined with corticosteroids.¹⁰
• Acupuncture may be helpful in the short term.¹¹
• Some surgeons perform manipulation under anaesthetic and arthroscopic release of the adhesions if conservative treatment fails.

• Long term pain and shoulder stiffness.

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

• Avoid prolonged immobilisation whatever the reason, e.g. slings, plaster casts, during illness.