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A review on frozen shoulder

Article  in  Singapore medical journal · September 2010

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 Review Article Singapore Med J 2010; 51(9) : 694

A review on frozen shoulder

Wong P L K, Tan H C A

ABSTRACT PATHOGENESIS AND COURSE

Of all the joints in the human body, the shoulder Knowledge of the pathogenesis and natural progression
has the greatest range of motion. This allows of any illness or disease contributes to decision-making in
complex movements and functions to be carried managing
1a a patient. Research conducted by the Nuffield
out, and is of vital importance to the activities of Orthopaedic Centre, Oxford, United Kingdom studied
daily living and work. Any restriction or pain that the pathology of primary frozen shoulder in 22 patients
involves the joint puts a huge amount of strain at a mean time from onset of 15 (range 3–36) months.
on patients, especially those who are in their Histology findings of tissue taken during manipulation
most productive years of life. Frozen shoulder, a under anaesthesia and arthroscopic release revealed the
frequently encountered disorder of the shoulder, presence of fibroblasts and chronic inflammatory cells.
has been well recognised since the early 1900s. The study concluded that the pathology of frozen shoulder
Although benign, it has great impact on the includes a chronic inflammatory response with fibroblastic
quality of life of patients. This article aims to proliferation.(7)
provide an overview of the nature and the widely Primary frozen shoulder generally progresses through
accepted management of this condition based on three clinical phases: (1) Painful phase, where there is a
other studies. gradual onset of aching shoulder, usually worst at night and
when lying on the affected side, and lasts for 2–9 months;
1b
Keywords: adhesive capsulitis, frozen shoulder, (2) Stiffening or frozen phase, in which the pain level is
shoulder joint often not altered and the patient experiences difficulty with
Singapore Med J 2010; 51(9): 694-697 simple activities of daily living. The stiffness progresses
and may lead to muscle wasting due to disuse atrophy. This
INTRODUCTION phase lasts for 4–12 months; and (3) Thawing phase, where
Frozen shoulder, a term coined by Codman in 1934, is the patient experiences a gradual increase in the range
an orthopaedic condition that is commonly encountered of movement and improvement in pain, although it may
in general practice. Codman used this term to describe a reappear as the stiffness eases. This phase lasts for 5–12
condition with symptoms of shoulder pain and discomfort months.
that is slow in onset and located around the deltoid insertion. In another study, Nuffield Orthopaedic Centre followed
Patients generally complain of an inability to sleep on up 223 patients with a diagnosis of primary frozen shoulder
the affected side. Restricted glenohumeral elevation and for an average of four years from the onset of symptoms,
external rotation, together with unremarkable radiographic so as to gauge the overall natural course of the disease. The
findings, are also observed. The condition can be broadly
(1)
results revealed that in the long term, slightly less than half
divided into two categories: primary, in which there are no (41%) of the patients reported some ongoing symptoms.
Department of
Orthopaedic Surgery, obvious causes, and secondary, where a cause is identified 94% of those who had ongoing symptoms only had mild
Sports Medicine
Service,
(from history, clinical examination and radiographic symptoms, while 6% had severe symptoms of pain and
Singapore General appearances). functional loss.(8) Shaffer et al monitored 68 patients for
Hospital,
Outram Road, Frozen shoulder mainly affects individuals 40–60 years approximately seven years, and found that on objective
Singapore 169608
of age, with a female predominance. The exact incidence motion measurement, about one-third of the patients were
Wong PLK, MBBCh and prevalence of frozen shoulder are unknown, but various restricted when compared with the opposite unaffected side,
BAO
Medical Officer authors have quoted figures of 2%–5% in the general while half had persistent pain or stiffness.(9) Hence, frozen
Tan HCA, MBBS, population. Nevertheless, those with diabetes, prolonged shoulder may in fact run a rather protracted course. This is
FRCSG, FRCSE
Senior Consultant
shoulder immobility (trauma, overuse injuries or surgery) unacceptable, especially for patients in their productive years
or systemic diseases (hyperthyroidism, hypothyroidism, of life, and suitable treatment should thus be administered.
Correspondence to:
Dr Kenneth Wong Pak cardiovascular disease or Parkinson’s disease) are at a higher
Leung
Tel: (65) 9235 5960 risk.(2,4) In addition, there is evidence that protease inhibitors PRESENTATION AND DIAGNOSIS
Tel: (65) 6224 8100 used for antiretroviral therapy have been associated with the History and examination
Email: kwpltkl@yahoo.
com development of frozen shoulder.(5,6) True frozen shoulder is a clinical diagnosis. The three
 Singapore Med J 2010; 51(9) : 695

hallmarks of frozen shoulder are progressive shoulder obliteration of the fat triangle between the CHL and the
stiffness, severe pain (especially at night) that results coracoid process), are characteristic findings in frozen
in the inability to sleep on the affected side and a near shoulder.(11) Nonetheless, MR imaging is performed
complete loss of passive and active external rotation of mainly to exclude rotator cuff tears or intra-articular
the shoulder. Proper history-taking includes the onset pathology and not for diagnosis per se. As with MR
and duration of symptoms, site, function and preceding imaging, ultrasonography is recommended only if the
trauma. Past medical and surgical history is relevant and physical examination indicates the possibility of another
should be obtained. On inspection, mild disuse atrophy shoulder pathology such as rotator cuff tears.
of the deltoid and supraspinatus in longstanding cases is
usually observed. The arm may be adducted and internally MANAGEMENT
rotated. Tenderness would be positive on palpation of Generally, frozen shoulder is a self-limiting condition.
the glenohumeral joint. Both active and passive range However, about 10% of patients experience long-term
of motion are affected, especially that of abduction and problems.(12) Considerable research has been conducted
external rotation. Movement in the thoracoscapular joint, with regard to the most effective approach to treatment. A
which may aid abduction, should be noted. broad overview of some of the well-recognised methods
In patients with a considerable amount of pain, a local today is provided below.
anaesthetic can be used. Those with frozen shoulder will
still have a decreased range of abduction and external CONSERVATIVE METHODS
rotation. The signs and symptoms of rotator cuff tendinitis Patient education
overlap with those of frozen shoulder. However, in contrast This is most important as it encourages compliance.
to the former, where pain is the main limiting factor, Informing the patient about the phases, course and
patients with pure frozen shoulder may complain of chronic duration of the condition usually aids in alleviating
pain; however, symptoms of stiffness predominate. In frustration. It is also imperative to emphasise that while
addition, the signs and symptoms of cervical radiculopathy the range of motion would improve, it may never be
and upper limb neurology should be evaluated, as cervical complete.
spondylosis or other cervical disc disease may lead to or
coincide with frozen shoulder. On the same note, cardiac Physiotherapy
2c
conditions, especially coronary artery disease, may present Conventionally, this encompasses the use of
with shoulder pain (referred pain). Ernstene et al reviewed weighted pendulum stretching followed by passive
133 cases of myocardial infarction and found 17 patients stretching exercises, which aims to stretch the lining
whose original complaint was shoulder pain.(10) Hence, of the glenohumeral joint. A study published in 2008
good cardiac history-taking and examination are advised. indicates the promising use of continuous passive
motion as compared to that of conventional practice.(13)
Laboratory studies and imaging Dierks and Stevens described a prospective study of
Laboratory studies do not contribute to the diagnosis of 77 patients that compared exercise within the limits
frozen shoulder. However, with regard to secondary frozen of pain with intensive physiotherapy in patients with
shoulder, certain tests, such as full blood count, erythrocyte idiopathic frozen shoulder. In this study, they found
sedimentation rate, C-reactive protein, serum blood glucose that exercise performed within the limits of pain (64%
and thyroid function tests, may be ordered if an undiagnosed reached near normal, painless shoulder movements at
comorbidity is suspected based on the history. 12 months and 89% at 24 months) yielded better results
Plain films of the shoulder should be routinely than that with intensive physiotherapy (63% achieved
taken to rule out any other pathology, and cervical spine a similar result at 24 months).(14) Improvement in
radiography should also be performed in cases of likely daily activities, pain relief and range of motion is
cervical disease. Magnetic resonance (MR) imaging may more significant with deep heating combined with
be required if another pathology is suspected based on the stretching exercises than with superficial heating
history and examination, or if the patient does not improve alone. (15)
after a period of time (usually around three months) of
conservative therapy. Research conducted in Switzerland Nonsteroidal anti-inflammatory drugs (NSAIDs)
concluded that thickening of the coracohumeral ligament As the pathology behind this condition is inflammatory,
(CHL) and the joint capsule in the rotator cuff interval, it would make sense to reduce the symptoms by
as well as the subcoracoid triangle sign (complete administering anti-inflammatory drugs. This, together
 Singapore Med J 2010; 51(9) : 696

with physiotherapy, is the mainstay of treatment for cases, especially in diabetics.(26,27) Ogilvie-Harris et
frozen shoulder. Its effectiveness has been proven al conducted a study on 17 diabetic patients with
through various prospective studies.(16) frozen shoulder who failed to respond to conservative
management, for which arthroscopic release was
Corticosteroids performed. At the 1–5 year follow-up, the patients
Studies have shown that adding steroids to the usual NSAID showed significant improvement in pain, external
and physiotherapy regime results in an improvement in pain rotation, abduction and function.(26) Pearsall et al
relief; however, the relief generally does not extend beyond reviewed and treated 43 patients with a diagnosis
six weeks. (17,18)
Corticosteriods can be administered orally of primary or secondary frozen shoulder who had
or via injection. A study conducted by Widiastuti-Samekto symptoms for an average of 12 months and who failed
and Sianturi revealed that intra-articular corticosteroid conservative treatment of at least 12 weeks of physical
injection provides faster improvement compared to the oral therapy. Following arthroscopic capsular release, all
route.(19)
the patients showed a significant reduction in shoulder
pain and improvement in shoulder range of motion.(28)
Electrical stimulation Holloway et al compared the results of arthroscopic
Either electroacupuncture or interferential electrotherapy, capsular release in three different groups of patients
in combination with shoulder exercises, is effective (idiopathic frozen shoulder, shoulder stiffness after
in treating patients with frozen shoulder. However, no surgery and shoulder stiffness after fracture) with
significant difference has been found between these two shoulder contracture refractory to those of conservative
types of treatment. (20)
management and manipulation under anaesthesia.
The results revealed that surgery provided benefits, in
SURGICAL METHODS terms of range of motion, to patients with postoperative
Shoulder manipulation contracture of the shoulder and to those with idiopathic
In some patients, if severe stiffness persists, gentle and post-fracture contractures. However, those in
manipulation of the shoulder while administering a general the postoperative group showed less improvement in
anaesthetic may improve shoulder motion and function for the subjective scores for pain, function and patient
a mean period of 15 years following treatment.(21) However, satisfaction.(29) Another study by Gerber et al concluded
studies have shown that this does not increase the benefit that the success of arthroscopic capsular release was
to an exercise program carried out by the patient under largely impacted by the severity of stiffness regardless
instructions by the clinician. (22)
Furthermore, Loew et al of the cause.(30)
have observed iatrogenic intra-articular lesions following The current indication for open surgical release includes
this procedure, which included bleeding, capsule rupture, cases that cannot be managed by arthroscopic means.
tendon and ligament tears, and osteochondral defects.(23) However, open surgery has significant disadvantages and
risks. It can be technically difficult to achieve a complete
Hydrodilation posterior capsule release via open release. Moreover, it
Quraishi et al compared the results of manipulation is associated with increased postoperative pain, a limited
under anaesthesia with hydrodilation in 36 patients who range of motion and extended hospital stay.(31) On the other
were followed up for six months. At the final follow- hand, arthroscopy is contraindicated in patients who cannot
up, 94% of the patients were either adequately satisfied tolerate fluid challenges (cardiac, renal insufficiency).
or highly satisfied with the results after hydrodilation, The treatment of choice for frozen shoulder is similar
as compared with 81% of those who received a to other conditions, which is conservative initially, but may
manipulation. Although most of the patients were eventually require more invasive methods depending on
successfully treated, those who underwent hydrodilation the expectations, functional demands and comorbidities
reported better results. (24)
A systematic review conducted of the patient. The indication for surgical treatment should
by Buchbinder et al concluded that short-term benefits be genuine failure of conservative treatment and not non-
with regard to pain, range of movement and function can compliance. In this day and age of easy access to information,
be achieved with arthrographic distension using saline and clinicians must equip themselves with sufficient knowledge
steroids.(25) so as to be able to filter and discuss treatment options with
patients. Patients themselves may come up with their “ideal”
Arthroscopic selective capsular release treatment, but ultimately, the choice of treatment rests on both
This is considered an effective treatment for resistant the doctor’s clinical judgement and the patient’s preference.
 Singapore Med J 2010; 51(9) : 697

REFERENCES short-course, pulse prednisolone in managing frozen shoulder. J

1. Codman EA. The Shoulder: Rupture of the Supraspinatus Tendon Pain Palliat Care Pharmacother 2007; 21:27-30.
and other Lesions in or about the Subacromial Bursa. Boston: 18. Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids
Thomas Todd Co, 1934. for adhesive capsulitis. Cochrane Database Syst Rev 2006 Oct
2. Pal B, Anderson J, Dick WC, Griffiths ID. Limitation of joint 18: CD006189.
mobility and shoulder capsulitis in insulin- and non-insulin- 19. Widiastuti-Samekto M, Sianturi GP. Frozen shoulder syndrome:
dependent diabetes mellitus. Br J Rheumatol 1986; 25:147-51. comparison of oral route corticosteroid and intra-articular
3. Milgrom C, Novack V, Weil Y, et al. Risk factors for idiopathic corticosteroid injection. Med J Malaysia 2004; 59:312-6.
frozen shoulder. Isr Med Assoc J 2008; 10:361-4. 20. Cheing GL, So EM, Chao CY. Effectiveness of
4. Riley D, Lang AE, Blair RD, Birnbaum A, Reid B. Frozen shoulder electroacupuncture and interferential electrotherapy in the
and other shoulder disturbances in Parkinson’s disease. J Neurol management of frozen shoulder. J Rehabil Med 2008; 40:166-70.
Neurosurg Psychiatry 1989; 52:63-6. 21. Farrell CM, Sperling JW, Cofield RH. Manipulation for frozen
5. Grasland A, Ziza JM, Raguin G, Pouchot J, Vinceneux P. Adhesive shoulder: long-term results. J Shoulder Elbow Surg 2005;
capsulitis of shoulder and treatment with protease inhibitors in 14:480-4.
patients with human immunodeficiency virus infection: report of 8 22. Kivimäki J, Pohjolainen T, Malmivaara A, et al. Manipulation
cases. J Rheumatol 2000; 27:2642-6. under anaesthesia with home exercises versus home exercises
6. Zabraniecki L, Doub A, Mularczyk M, et al. Frozen shoulder: a new alone in the treatment of frozen shoulder: a randomized,
delayed complication of protease inhibitor therapy? Rev Rhum Engl controlled trial with 125 patients. J Shoulder Elbow Surg 2007;
Ed 1998; 65:72-4. 16:722-6.
7. Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of 23. Loew M, Heichel TO, Lehner B. Intraarticular lesions in primary
frozen shoulder. J Bone Joint Surg Br. 2007; 89:928-32. frozen shoulder after manipulation under general anaesthesia. J
8. Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of Shoulder Elbow Surg 2005; 14:16-23.
frozen shoulder. J Shoulder Elbow Surg 2008; 17:231-6. 24. Quraishi NA, Johnston P, Bayer J, Crowe M, Chakrabarti AJ.
9. Shaffer B, Tibone JE, Kerlan RK. Frozen Shoulder. A long-term Thawing the frozen shoulder. A randomised trial comparing
follow up. J Bone Joint Surg Am 1992; 74:738-46. manipulation under anaesthesia with hydrodilatation. J Bone
10. Ernstene AC, Kinell J. Pain in the shoulder as a sequel to myocardial Joint Surg Br 2007; 89:1197-200.
infarction. Arch Intern Med 1940; 66:800-6. 25. Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston
11. Mengiardi B, Pfirrmann CW, Gerber C, Hodler J, Zanetti M. Frozen M. Arthrographic distension for adhesive capsulitis (frozen
shoulder: MR arthrographic findings. Radiology 2004; 233:486-92. shoulder). Cochrane Database Syst Rev 2008 Jan 23: CD007005.
12. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay M. The resistant Review.
frozen shoulder. Manipulation versus arthroscopic release. Clin 26. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay M. The
Orthop Relat Res 1995; (319):238-48. resistant frozen shoulder. Manipulation versus arthroscopic
13. Dundar U, Toktas H, Cakir T, Evcik D, Kavuncu V. Continuous release. Clin Orthop Relat Res 1995; 319:238-48.
passive motion provides good pain control in patients with adhesive 27. Ogilvie-Harris DJ, Myerthall S. The diabetic frozen shoulder:
capsulitis. Int J Rehabil Res 2009; 32:193-8. arthroscopic release. Arthroscopy 1997; 13:1-8.
14. Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: 28. Pearsall AW 4th, Osbahr DC, Speer KP. An arthroscopic
a prospective study of supervised neglect versus intensive technique for treating patients with frozen shoulder. Arthroscopy
physical therapy in seventy seven patients with frozen shoulder 1999; 15:2-11.
syndrome followed up for two years. J Shoulder Elbow Surg 2004; 29. Holloway GB, Schenk T, Williams GR, Ramsey ML, Iannotti
13:499-502. JP. Arthroscopic capsular release for the treatment of refractory
15. Leung MS, Cheing GL. Effects of deep and superficial heating in the postoperative or post-fracture shoulder stiffness. J Bone Joint
management of frozen shoulder. J Rehabil Med 2008; 40:145-50. Surg Am 2001; 83-A:1682-7.
16. Dudkiewicz I, Oran A, Salai M, Palti R, Pritsch M. Idiopathic 30. Gerber C, Espinosa N, Perren TG. Arthroscopic treatment of
adhesive capsulitis: long-term results of conservative treatment. Isr shoulder stiffness. Clin Orthop Relat Res 2001; (390):119-28.
Med Assoc J. 2004; 6:524-6. 31. Rockwood CA, Matsen FA, Wirth MA, Lippitt SB. The Shoulder.
17. Saeidian SR, Hemmati AA, Haghighi MH. Pain relieving effect of 3rd ed. Philadelphia: Saunders, 2004: 1155-7.

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