Charlie Kornberg's Musculoskeletal Physiotherapy Home Page

Adhesive Capsulitis/Frozen Shoulder

There are 2 types of adhesive capsulitis:

idiopathic or primary: of no identifiable cause
secondary: results from other pathological states e.g. trauma

There is a gradual tightening of the capsule of the shoulder resulting in a significant limitation in movement.

The exact pathology and trigger factors are not clear. What we do know is that inflammation occurs and adhesions/scar tissue forms.

Authors describe a number of predisposing factors:

OA, diabetes, shoulder trauma (including surgery), open heart surgery, hyperthyroidism, history of cervical disc disease are all associated with an increased risk for this problem. Post viral infection and relative immobility are also noted factors.

What essentially happens is a global reduction of all shoulder movements. It affects 2 – 3% of the population; tends to occur in people older than 40 but more commonly in the 50s and more commonly in women; 15 - 30% of sufferers go on to have it in both shoulders. 20% of diabetics have been shown to suffer from this condition.

Typically characterized by 3 stages:

1. Freezing (Painful) – this is the extremely painful stage: patient is reluctant to move because of pain – hence movement is not actually restricted by capsule tightening … yet! This stage can last between 3 – 8 months. Often the first sign is the inability to raise the arm or reach behind e.g. wallet or shirt tuck. Sleep disturbances are very common – both with lying on the shoulder and the highly inflammatory nature of the pain.

The frozen shoulder joint and inflammation.

2. Frozen (Adhesive) – this is the adhesive stage, involves increasing stiffness with diminishing pain. Pain decreases at night, and discomfort occurs only at the extremes of motion, although movement is dramatically decreased. This stage can last between four - six months.

Frozen shoulder inflammation creating significant capsular thickening.

3. Thawing (Recovery) – this is the recovery stage, lasting between one - three months. Characterized by minimal pain but severe restriction of movement. Complete recovery, however, is infrequent. Approximately 7 - 15 percent of patients permanently lose their full range of motion, although a figure of 40% has been bandied about.

Treatment

Painful stage

Physiotherapy (non-aggressive) NSAIDs, intra-articular cortisone injections and analgesics – may provide some benefit. Aggressive therapy often makes it worse. Evidence suggests use of cortisone orally (Monash Uni trial showed effective use of 30mg Prednisolone for 3 weeks) is most effective in slowing the inflammatory process and hence decreasing pain.

Adhesive Stage

Physiotherapy including exercises has traditionally been used. No evidence showing this, on its own, is more effective than time progression itself. Lots of anecdotal evidence though.

Hydrodilatation – injecting a volume of saline into the shoulder joint capsule – primarily to physically stretch the joint “from the inside” has been pioneered by a radiology clinic in Prahran in 1989. Local anaesthetic injected into joint – then up to 35 mls of saline gradually introduced into the joint to break down adhesions. Can’t be done too early as may increase inflammation.

A randomized double blind placebo-controlled trial of hydrodilatation has demonstrated at least short-term efficacy of hydrodilatation over placebo in patients with frozen shoulder. Then a 6 week course of physiotherapy following the hydrodilatation has shown to be effective to decrease pain, improve range of motion, and shortens the duration of the condition.

Some other treatments include manipulation under anaesthesia and surgery – no evidence exists that these are effective in reducing the natural time progression of the condition.

The concepts presented here are entirely the author's own (unless expressly stated) and do not represent the thoughts or ideas of any other person.

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