What is Frozen Shoulder / Adhesive Capsulitis?

We often see people with various shoulder problems, such as rotator cuff injuries. We have an excellent blog post titled Rotator Cuff Tears: Does the size of shoulder rotator cuff tears relate to the amount of pain experienced? One of the more challenging shoulder conditions we treat is called Adhesive Capsulitis.

What Is Adhesive capsulitis?

Adhesive capsulitis, more commonly known as “frozen shoulder” is a disabling musculoskeletal condition causing spontaneous chronic shoulder pain and the gradual loss of shoulder motion. The shoulder joint, also called glenohumeral joint is like a ball and saucer joint, rather than a ball and socket joint like the hip joint. The lubricating fluid (synovial fluid) in this joint is surrounded by a capsule made of strong connective tissue.

With frozen shoulders the capsule contracts, thickens and tightens and bands of tissue known as adhesions develop causing parts of the capsule to adhere to itself.

What is the incidence of Frozen Shoulder?

Frozen shoulder has an incidence rate of 3-5% in the general population and up to 20% of those with diabetes mellitus. Adhesive capsulitis has been shown to have a higher incidence in those with co-morbidities such as; hyperthyroidism, hypothyroidism, hypoadrenalism, Parkinson’s disease, cardiac disease, pulmonary disease, stroke and even those who have recently had a surgical procedure (Manske & Prohaska, 2008, p. 180).

Adhesive capsulitis is classified into two categories, primary or secondary adhesive capsulitis. Those with primary adhesive capsulitis generally have very gradual onset and progression of symptoms, with no known precipitating event that can be identified.

Secondary adhesive capsulitis is generally due to trauma or subsequent immobilisation (Manske & Prohaska, 2008, p. 181).

What are the Three Phases of Frozen Shoulder?

Frozen shoulder often follows three phases. The first stage is called the freezing or painful stage which involves worsening pain and a declining range of motion and can last 3-9 months. Second stage, frozen or transitional stage, can last 4-12 months and involves limited range of motion and severe pain resulting in muscular disuse. Third and final stage, termed the thawing stage, begins when range of motion begins to return and can last anywhere from 12-42 months.

Regularly, we see cases which have a more non-classical path over time. For example decreasing range not accompanied by significant pain. Jonathan Clerke has seen a case or two of bilateral frozen shoulder, but usually adhesive capsulitis only impacts one shoulder at a time. Bilateral adhesive capsulitis has a very significant effect on a person’s abilities. The disease can recur in some patients and Jonathan has seen such people.

What treatments are available for a frozen shoulder?

Treatment for adhesive capsulitis has often included use of prescribed oral non- steroidal anti-inflammatories, a corticosteroid injection, physiotherapy and hydrodilatation also known as capsular distension injection. Surgically related treatments include manipulation under anaesthesia (to forcibly rupture the contracted capsule) and arthroscopic release & repair (keyhole surgery where the thickened capsule is cut and removed using a radiofrequency thermal probe). (Wang et al., 2017).

We have had the privilege of treating people with frozen shoulder and seeing measurable favourable changes as a result. However such treatment is never a ‘quick fix’.

What is a corticosteroid injection and where does it go?

Corticosteroids (cortisone) are very powerful anti-inflammatory agents that can provide some relief for several weeks or even months. Steroids in pill form are not often prescribed for people with frozen shoulder because they can cause widespread side effects. Injections tend to be more effective. When using corticosteroids, the treating physician might typically inject them directly into the shoulder joint (glenohumeral or intra-articular injection) or into the subacromial space (Xiao et al., 2017). The sub-acromial space sits just above the true ball and saucer shoulder joint glenohumeral joint.

Cortisone injections provide relief for a limited time and work best if given early in the development of symptoms. A large scale comparison of research on corticosteroid injections in the shoulder joint found that whilst injections reduced pain for first 8 weeks there was no difference between those who received injections and those who received a placebo treatment at the 9 to 24 week marks (Wang et al., 2017). Apparently it’s not always easy to get the needle into the right spot in the joint, so the medication does not always end up where it is needed. Many doctors use imaging when they inject to ensure the target is reached.

What is shoulder hydrodilatation (aka capsular distension injection)?

Hydrodilatation (also called distension and hydrodistension) aims at physically distending the shoulder joint capsule, akin to blowing up a balloon. It involves injection of a large amount of saline (a salty solution) containing steroid, local anaesthetic and contrast material (dye or substance that has different opacity when viewed radiologically) into the glenohumeral joint while imaging the joint at the same time. Imaging ensures that the target is reached. This procedure is quick, technically easy to perform and is less invasive than actual surgery. However despite being a treatment modality used with adhesive capsulitis for 50 years, the evidence on its effectiveness is not clear. A comparison (called a meta-analysis) of seven randomly controlled trials done in 2018 found that whilst there was pain reduction and increased range of motion following this treatment, at least 12 patients needed to undergo the procedure in order for one to achieve any improvement compared to the control group (Saltychev et al., 2018)

We hope that you never have this condition, but if you do we would welcome the opportunity to help.

References

1. Manske, R. C., & Prohaska, D. (2008). Diagnosis and management of adhesive capsulitis. Current reviews in musculoskeletal medicine, 1(3-4), 180-189.
2. Saltychev, M., Laimi, K., Virolainen, P., & Fredericson, M. (2018). Effectiveness of hydrodilatation in adhesive capsulitis of shoulder: A systematic review and meta-analysis. Scandinavian Journal of Surgery, 107(4), 285-293.
3. Wang, W., Shi, M., Zhou, C., Shi, Z., Cai, X., Lin, T., & Yan, S. (2017). Effectiveness of corticosteroid injections in adhesive capsulitis of shoulder. Medicine, 96(28), e7529.

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