The Frozen Shoulder
Adhesive capsulitis (aka frozen shoulder, painful stiff shoulder or periarthritis) is a self-limiting condition where the bones, tendons or ligaments cause pain on movement. Frozen shoulder later progresses too restricted active AND passive glenohumeral ROM. There is disagreement whether it stems from an inflammatory, fibrosing or algoneurodystrophic (a form of complex regional pain syndrome without demonstrable nerve lesions) conditions.
Frozen shoulder can affect the antero-superior joint capsule, axillary recess and the coracohumeral ligament. Common findings may include a small joint with loss of axillary fold, tight anterior capsule, and synovitis but no adhesions. The space surrounding the GHJ has been suspected to reduce from 15-35 cubic centimetres to 5-6cm.
Ethology of frozen shoulder
Frozen shoulder is classified as either primary (idiopathic onset) or secondary (a direct cause). Secondary onsets could include:
- systemic (diabetes/metabolic conditions/hypothyroidism)
- extrinsic (CVA, Parkinson’s, direct trauma)
- intrinsic (rotator cuff/other shoulder muscle pathologies) factors of origin
It is also known as the 50 year old shoulder since it is much more prevalent in this age group. It is especially common in females over the age of 40 and those who are recovering from a mastectomy are at greater risk.
Frozen shoulder can be challenging to differentiate in the early stages from other shoulder pathologies. One of the main presenting factors is loss of external rotation. Restrictions in a capsular pattern present as ER limitations > Abd limitations > IR limitations. Patients may also complain of difficulties with dressing, overhead activities, grooming. Symptoms may also worsen at night.
The time frame for recovery varies greatly from 6 months to 11 years which could be spontaneous complete recovery or nearly-complete. Most tend to resolve around 3 years. Unfortunately, some patients’ symptoms may never fully resolve (estimated to be around 15%).
The three overlapping phases include:
1. Acute/freezing/painful phase: sharp pain with sleep interruptions – 2-9months
2. Adhesive/frozen/stiffening phase: pain decreases lingering at end ROM, ROM decreases in a capsular pattern – 4-12months
3. Resolution/thawing phase: spontaneous improvement in ROM – 5-24months Physical exam is usually sufficient to diagnose frozen shoulder, however X-rays, US or MRI can help rule out other issues.