Frozen Shoulder

Aka: Frozen Shoulder, Shoulder Adhesive Capsulitis, Adhesive Capsulitis

1. Definition
   1. Shoulder Pain and limited range of motion stemming from disuse
2. Epidemiology
   1. Age over 40 years
   2. Women more commonly affected
3. Risk Factors
   1. Chronic Shoulder Pain (results in disuse)
      1. Bicipital Tenosynovitis
      2. Rotator Cuff Tendinitis
      3. Shoulder Band Syndrome (Reflex Sympathetic Dystrophy)
   2. Comorbid conditions that predispose to Adhesive Capsulitis
      1. Diabetes Mellitus
      2. Thyroid Disease
4. Symptoms
   1. Gradual onset of decreased Shoulder stiffness
   2. Pain onset after significant Shoulder Range of Motion lost
   3. Pain well localized to rotator cuff
   4. Pain radiation into deltoid and anterior arm
   5. Pain interferes with sleep (unable to lie on Shoulder)
5. Signs
   1. Inspection
      1. Patient holds arm protectively at side
      2. Deltoid and Supraspinatus atrophy
   2. Palpation
      1. Generalized pain at rotator cuff and biceps tendon
   3. Limited range of motion
      1. Loss of both active and passive Shoulder Range of Motion (pathognomonic)
      2. Loss of motion in all planes
      3. Normal range of motion excludes Adhesive Capsulitis as a diagnosis
   4. Associated Findings: Reflex Sympathetic Dystrophy
      1. Hand Edema, coolness, and discoloration
6. Differential Diagnosis
   1. See Shoulder Pain
7. Imaging: Shoulder XRay
   1. Typically normal in Adhesive Capsulitis
   2. Evaluate differential diagnosis
      1. Posterior Shoulder Dislocation
      2. Glenohumeral Osteoarthritis
8. Management
   1. Conservative measures to relieve pain
      1. Rest
      2. Moist heat
      3. Sedation
      4. Analgesics
   2. Physical Therapy (Start as soon as possible)
      1. See Shoulder Range of Motion Exercises
      2. Avoid aggressive mobilization as it may prolong the course
      3. Initially, home Exercises are performed hourly
   3. Oral Corticosteroid
      1. Prednisone 20 mg orally daily for 3-4 weeks
      2. Superior to physical therapy or Acetaminophen is improved function and decreased pain in the first 1-2 months
   4. Subacromial Corticosteroid Injection
      1. Indicated at 6 weeks for course refractory to conservative measures and physical therapy
      2. Restart Shoulder Range of Motion Exercises at 1 week after injection
      3. Ryans (2005) Rheumatology 44:529-35
   5. Surgical Intervention (rarely needed now)
      1. Indicated for intolerable symptoms at 6-12 weeks refractory to above measures
      2. Procedures
         1. Careful Shoulder manipulation under general anesthesia
            1. Exercise caution in patients with Osteoporosis, Osteopenia or Glenohumeral Instability
            2. Risk of Proximal Humerus Fracture
            3. Glenohumeral Dislocation
            4. Rotator Cuff Tear
         2. Capsular release by Shoulder arthroscopy
         3. Cervical Sympathetic Nerve blocks (used historically for refractory pain control)
9. Prevention
   1. Maintain Shoulder Range of Motion at time of injury
   2. See Shoulder Range of Motion Exercises
10. Course
    1. Insidious onset of pain
    2. Chronic, full recovery may take over 6 months
    3. Most regain near full motion of Shoulder within 1-2 years even without intervention
11. References
    1. Burbank (2008) Am Fam Physician 77:493-7
    2. Griggs (2000) J Bone Joint Surg Am 82-A:1398-407
    3. Ewald (2011) Am Fam Physician 83(4): 417-22