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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.

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

Stiffness, pain and loss of motion with insidious onset are usually the major symptoms.6

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 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.
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 for > 6 months despite appropriate conservative management.3
Prevention
  • Avoid prolonged immobilisation whatever the reason, 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. Last Updated Jun 6, 2007.
  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. Green S, Buchbinder R, Hetrick S; Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;(2):CD004258. [abstract]
  10. 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.
  11. Green S, Buchbinder R, Hetrick S; Acupuncture for shoulder pain. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD005319. [abstract]
Internet and further reading Acknowledgements EMIS is grateful to Dr M Preston for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 2802
Document Version: 20
DocRef: bgp1866
Last Updated: 18 Jan 2008
Review Date: 17 Jan 2010


















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