Frozen shoulder

Definition

Adhesive capsulitis (frozen shoulder) is a lesion of the capsule of the shoulder joint accompanied by significant restriction of movement. The joint itself is not involved in the process. The disease proceeds in stages: first, there is pain; then, there is a limitation of movement, after which the limb’s function is gradually restored. Recovery occurs in 1.5-4 years from the onset of the first symptoms. Diagnosis is based on anamnesis, complaints, and objective examination data; instrumental and laboratory techniques are prescribed to exclude other pathologies. Treatment is conservative: drug therapy, stretching the joint capsule, limiting and then increasing the load.

General information

Adhesive capsulitis is a disease that causes severe impairment of limb function and causes prolonged disability, but has a favorable prognosis and ends with recovery. It is diagnosed in about 2% of the population. Usually occurs at the age of 50-70 years, women suffer 3-5 times more often than men. It affects the dominant and non-dominant hand equally often. In 7-10% of patients, the adhesive process is bilateral, with symptoms in the second shoulder region appearing within several months to several years from the debut of the disease.

Causes

Although the causes of adhesive capsulitis have not yet been established, researchers believe that trophic disorders provoke the disease due to nervous regulation disorders. 

Adhesive capsulitis can form on its own or be provoked by other conditions. Conditions that most commonly cause capsular fibrosis include:

• diabetes;
• malignant neoplasms;
• hyperthyroidism;
• stroke and myocardial infarction;
• condition after heart surgery.

The most common cause of the secondary adhesive process is type II diabetes mellitus – the disease is identified in one in three people with diabetes. The association between capsulitis and tendonitis (the most frequent pathology causing shoulder pain) is not supported by research data.

Classification

Adhesive capsulitis is characterized by a pronounced stage course with a gradual change in symptomatology. Modern orthopedics distinguishes three phases of the disease:

• Pain. Takes 3 to 12 months. It is accompanied by pain syndrome and a gradual decrease in the volume of movement.
• Rigor. The duration is approximately equal to the previous stage. Pain decreases and disappears, movements are sharply limited.
• Recovery. The duration is 1-2 years. Movements are gradually restored, although in some cases they do not reach the volume they had before the onset of the disease.

The duration of each phase and the overall duration of capsulitis is determined by many factors, including the onset of treatment, concomitant pathologies, etc. Usually, the time intervals during which each phase lasts are proportional to each other. If the pain phase is prolonged, rigor and thawing will also be prolonged.

Symptoms of adhesive capsulitis

The pain appears for no apparent reason; less often, it occurs after overload or minor trauma. It gradually increases over 1-3 weeks and then begins to bother the patient at night. The patient wakes up with pain and cannot sleep on the side of the lesion. Against the background of pain syndrome, mobility is limited, and not immediately in all directions but in a certain sequence.

At first, the range of motion in turning the arm to the outside is reduced. At the same time, the extension is restricted to a lesser extent. Then, there are problems when rotating the shoulder to the inside. Difficulties are noted in performing ordinary household activities—eating, washing, combing, dressing and undressing, and turning the key in the keyhole. After a few months, the joint becomes almost completely blocked.

Pain syndrome persists, sometimes combined with swelling and impaired mobility of the distal parts of the limb (hand and wrist). Debilitating pain and disability stimulate patients to seek medical attention, but diagnosis of adhesive capsulitis is often difficult due to the lack of pathognomonic symptoms.

In the rigor phase, the pain gradually decreases, practically disappears at rest, and appears only when attempting to move the shoulder joint. Movement is still sharply limited. The ability to work is lost. On average, after 7-8 months, the range of motion gradually begins to increase, and the process continues in the thawing phase until complete or almost complete recovery.

Diagnosis

The diagnosis is made by orthopedic or rheumatologic physicians. Diagnosis is based on anamnestic data and the results of physical examination. The only informative instrumental method is arthrography, but it is almost never used in clinical practice due to invasiveness and lack of sufficient clinical information. Taking into account the phase, objective examination reveals:

• Phase 1. The deltoid muscle on the affected side is reduced in volume. During palpation, there is diffuse soreness in the area of the shoulder joint. Active and passive movements are equally limited – this sign allows differentiating adhesive capsulitis from other pathologies with similar symptoms.
• Phase 2. Muscle hypotrophy becomes more pronounced. Passive and active movements are limited to the same extent, but now due to mechanical obstruction. Pain is absent or weakly expressed.
• Phase 3. The degree of joint function recovery varies considerably depending on the time elapsed since the beginning of the phase. The diagnosis is confirmed on the basis of a characteristic history. The patient reports that the shoulder was initially painful, then did not move, and is now “working out.”

Adhesive capsulitis is differentiated from arthritis, rheumatic polymyalgia, chondromatosis, aseptic necrosis of the humeral head, Milwaukee syndrome, and malignant tumors. In the course of differential diagnosis, an analysis for C-reactive protein is prescribed, ESR is determined, radiography is performed. According to laboratory tests, there are no changes, on radiographs with a long course, osteoporosis may be detected.

Treatment of adhesive capsulitis

Treatment is carried out in outpatient settings, determined by the stage of pathology. An important part of therapy is forming confidence in the patient in a favorable outcome, allowing to avoid the development of neurotic disorders. Therapeutic measures for primary and secondary forms of the adhesive process are identical, the only difference is the restriction of the intake of hormonal agents in diabetes mellitus.

Treatment in the pain phase

The main goal of adhesive capsulitis therapy during this period is to reduce the pain syndrome. Treatment includes medication and non-medication measures:

• Protective regimen. Limitation of load on the shoulder joint is ensured. Immobilization is used in moderation to prevent the development of stiffness. In case of intense pain, it is recommended to use a bandage not more than a few hours daily.
• NSAIDs. Nonsteroidal drugs are prescribed in tablets in a daily dose of no more than 200 mg. The duration of intake and dose are determined taking into account the severity and duration of the pain syndrome. 
• Hormonal agents. Intra-articular blockades with corticosteroids are performed early because this allows reducing the duration of the painful phase of capsulitis. If pain resumes, the procedure is repeated in 2-3 weeks. The course of treatment includes no more than three blockades.

If the above methods are ineffective or hormonal drugs cannot be used in patients with diabetes mellitus, intra-articular injections of hyaluronic acid-based drugs are used, and suprascapular nerve blockades are performed. Physiotherapeutic methods for patients with adhesive capsulitis are usually not indicated due to insufficient effect. 

Treatment in the rigor and recovery phases

After the intensity of the pain syndrome has decreased, the protective regimen and drug therapy are discontinued. The main focus is on intensive development and stretching of the joint capsule. The patient is taught exercises that should be performed for several months. Special simulators for dosed stretching are used.

Redressing is rarely performed; the indication for active surgical mobilization is the absence of an increase in the volume of movement for six months or more after the onset of the second phase of the adhesive process if the patient wishes to accelerate recovery. Sometimes, partial mobilization is performed using arthroscopic equipment. Arthroscopic synovectomy may be performed if there are symptoms of synovitis.

All these treatment options are available in more than 900 hospitals worldwide (https://doctor.global/results/diseases/frozen-shoulder).  For example, Frozen shoulder surgery can be performed in these countries for a following approximate prices:

Turkey$1.9 K in 29 clinics

Germany$8.7 K in 46 clinics

United States$10.9 K in 26 clinics

China$11.2 K in 6 clinics

Israel$14.5 K in 14 clinics.

Prognosis and prevention

The prognosis in adhesive capsulitis is favorable; after the thawing phase, half of the patients regain full range of motion. In the other half, the outcome is a slight limitation of function that does not affect the ability to work or self-care. Prophylactic measures have not been developed because the etiology of the disease is unclear.