Frozen Shoulder (Adhesive Capsulitis)

What it is?

 Adhesive capsulitis (also known as frozen shoulder) is a condition of the shoulder causing increasing pain and loss of active and passive range of movement.

It results from inflammation of the glenohumeral joint and its surrounding capsule, along with fibrotic changes to the capsuloligamentous complex. The condition can occur in isolation or concurrently with other shoulder conditions like rotator cuff tear/tendinopathy, subacromial bursitis and has a strong associated risk for developing in individuals with diabetes mellitus. The patient can continue to experience symptoms and restrictions for up to 12 to 18 months.

 How it presents?

Adhesive capsulitis typically presents with a gradual and progressive onset of pain and shoulder stiffness. Pain is commonly felt at the end of range of movement of the shoulder and can also be felt at night, causing sleep disruptions.

Pain  usually presents as a poorly localised deep ache, which may radiate down the anterior or posterior upper arm. Pain is associated with restricted active and passive range of movement at the shoulder. Most common is a loss of external rotation (turning the arm out), followed by internal rotation, abduction and elevation.

The pain and/or restriction results in increasing difficulties with functional activities such as reaching overhead, reaching behind the back, or out to the side.

Adhesive capsulitis commonly occurs in individuals aged between 40-65 years old, with the peak occurrences in 50-55 year olds, with females having a greater risk than men. Individuals with a previous episode of adhesive capsulitis in the opposite arm and those with Diabetes Mellitus are all at greater risk of developing adhesive capsulitis.

How do we assess?

Diagnosis of adhesive capsulitis is primarily proved through clinical examination from a physiotherapist, however imaging can be used to exclude other shoulder conditions.

Patients are diagnosed with adhesive capsulitis if they have had shoulder pain for at “least 1 month, sleep disturbance due to pain, an inability to lie on the affected shoulder, restriction in all active and passive shoulder movements, and at least a 50% reduction in external rotation movement” (Kelley et al, 2013).

Your physiotherapist will assess for impairments in the glenohumeral joint, capsuloligamentous complex and musculotendinous structures surrounding the shoulder capsule. Whilst continuing to perform a full examination to ensure no other possible pathologies are not present.

Imaging through ultrasound (US) and magnetic resonance imaging (MRI) can identify possible coracohumeral ligament and joint capsule thickening and may help to identifying soft tissue and bony abnormalities.

What can we do?

Current evidence suggests that the best management for individuals with adhesive capsulitis is through a combination of medical and physiotherapy management. Once identified, current evidence for medical management has shown that hydrodilatation has significant improvement in individual’s symptoms. This procedure involves a large amount of saline solution and corticosteroid being injected into the patient’s glenohumeral joint to help stretch the fibrous shoulder capsule.

The role of the physiotherapy for individuals with adhesive capsulitis is to educate the patient on the condition and its progression and to provide joint mobilisation and stretching to the affected shoulder. The physiotherapist will also provided the patient with a tailored exercise program to be performed at home to decrease symptoms of pain and improve the mobility and function of the shoulder.

Management may also involve treatment of the neck or thoracic spine as stiffness in these areas can impact on shoulder mobility. Strengthening exercises may also be incorporated into the exercise regime as the rotator cuff often becomes weak due to prolonged periods of pain and reduced shoulder mobility.