What is a frozen shoulder and how is it treated?

Frozen Shoulder: Definition and Treatment

Frozen shoulder (adhesive capsulitis) is a painful condition characterized by progressive stiffness and limited range of motion in the shoulder joint that typically progresses through three phases (freezing, frozen, and thawing) and should be treated with a combination of physical therapy, intra-articular corticosteroid injections, and patient education on positioning and range of motion exercises. 1

Definition and Pathophysiology

Frozen shoulder is a condition characterized by:

• Fibrosis of the glenohumeral joint capsule with chronic inflammatory response 2
• Progressive limitation in both active and passive range of motion 3
• Typical progression through three distinct phases:
  1. Freezing phase: Marked by significant pain and initial loss of motion
  2. Frozen phase: Characterized by stiffness and severely limited mobility
  3. Thawing phase: Gradual return of shoulder motion 4

The condition affects approximately 5% of the general population and can last anywhere from 1 to 24 months 2. While often self-limiting, early intervention is crucial to prevent prolonged disability.

Diagnosis

Plain radiography is the preferred initial imaging study for shoulder pain evaluation 1:

• Standard views should include anteroposterior (AP) views in internal and external rotation
• An axillary or scapula-Y view is recommended

Advanced imaging such as MRI should not be used before plain radiographs but may be necessary if other pathology is suspected 1.

Treatment Approach

First-Line Interventions

1. Patient Education:

   • Proper positioning and range of motion exercises
   • Explanation of the natural course of the condition 1

2. Physical Therapy:

   • Gentle stretching and mobilization techniques focusing on external rotation and abduction
   • Progressive active range of motion exercises
   • Avoid overhead pulley exercises for hemiplegic shoulder pain 1
   • Begin physical therapy early to prevent permanent dysfunction 1

3. Pain Management:

   • Analgesics (acetaminophen, NSAIDs) if no contraindications 1

Second-Line Interventions

1. Intra-articular Corticosteroid Injections:

   • Strong evidence supports glenohumeral intra-articular corticosteroid injections for significant pain relief
   • These injections have a significantly greater 4-6 week beneficial effect compared to other treatments 3
   • Methylprednisolone acetate 40mg with lidocaine 1% provides more rapid pain relief compared to triamcinolone 1

2. Nerve Blocks:

   • Suprascapular nerve blocks are as effective as glenohumeral triamcinolone injections for non-neuropathic shoulder pain 1
   • Can provide pain relief for up to 12 weeks

Advanced Interventions

1. Joint Hydrodistension:

   • Ultrasound-assisted hydrodistention of the glenohumeral joint combined with targeted exercise has shown success in improving pain relief and increasing range of motion, especially when diagnosed before phase 2 5

2. Surgical Options (for recalcitrant cases):

   • Manipulation under anesthesia
   • Arthroscopic release 3
   • Consider surgical referral if conservative management fails after 3-6 months 1

Treatment Progression Based on Phase

Freezing Phase (High Irritability)

• Focus on pain control with analgesics and corticosteroid injections
• Gentle range of motion exercises
• Patient education on positioning

Frozen Phase (Moderate Irritability)

• More aggressive stretching and joint mobilization
• Continue pain management
• Focus on regaining external rotation and abduction 1

Thawing Phase (Low Irritability)

• Progressive strengthening exercises
• Functional rehabilitation
• Return to normal activities

Prognosis

Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 1. However, some patients may experience symptoms for up to 2 years.

Important Considerations

• Avoid immobilization: Shoulder immobilization with arm slings or wraps should be avoided as it can worsen the condition 1
• Early intervention: Delaying physical therapy intervention should be avoided, as early treatment is crucial 1
• Regular reassessment: Monitor progress and adjust treatment approach based on response

Common Pitfalls to Avoid

1. Overreliance on imaging without proper clinical assessment
2. Delaying physical therapy intervention
3. Using overhead pulley exercises which may worsen symptoms
4. Immobilizing the shoulder which can lead to further stiffness
5. Failing to provide intra-articular corticosteroid injections when indicated