Painful and frozen shoulder (adhesive capsulitis)

Stiff shoulder, primary adhesive capsulitis or frozen shoulder is a condition characterised by loss of both active and passive movement in the shoulder. Its causes are still unclear. We do know, however, that certain factors are associated with adhesive capsulitis: female sex, age over 40, a previous injury, diabetes, long immobilisation, thyroid disease, heart attack, stroke and autoimmune diseases.

A distinction is made between primary adhesive capsulitis, which results from a known internal or external cause, and secondary adhesive capsulitis, which results from surgery.

Primary adhesive capsulitis begins with pain that gradually eases but leaves reduced movement in the shoulder joint. The pain gradually stops, while the poor range of motion remains.

There are many ways to treat adhesive capsulitis: supervised physiotherapy, non-steroidal anti-inflammatory drugs, intra-articular corticosteroid injections, manipulation, arthrography and arthroscopic surgical release. Opinions differ on whether the underlying changes are inflammatory or simply fibrosis of the tissue. In fact, adhesive capsulitis is both: inflammation and fibrosis of the joint capsule.

The four stages of adhesive capsulitis

1. The first stage is marked by pain lasting less than three months. Arthroscopy shows a hypertrophic, highly vascularised synovial lining.
2. In the second stage, symptoms have been present for three to nine months and joint movement gradually worsens.
3. In the third stage, patients describe a stiff shoulder with loss of movement. Symptoms have been present for nine to fifteen months. Pain varies from very severe to fading.
4. The fourth stage is marked by a slow improvement in shoulder movement.

Diagnosis

Primary capsulitis is diagnosed from the medical history and a clinical examination. It is an idiopathic condition, so the diagnosis is made once other possible causes of shoulder pain and restricted movement have been ruled out. The examination should also include the cervical spine and the whole shoulder. Assessing active and passive movement is important for choosing the treatment.

X-rays of the shoulder in all projections, including internal and external rotation and a Y view, are also important for the diagnosis. An MRI scan can help clarify the diagnosis by showing the condition of the rotator cuff and labrum.

Treatment

In the first phase, adhesive capsulitis is treated with a non-steroidal anti-inflammatory drug, adjusted to the level of pain. An intra-articular injection of local anaesthetic and corticosteroid can be added; it is very useful both for diagnosing and for treating adhesive capsulitis. Treatment continues with physiotherapy supervised by a physiotherapist. In the first stage, the aim of rehabilitation is to break the cycle of inflammation and pain. Various forms of therapy can be added, from ultrasound to magnetic therapy. Hydrotherapy can follow, which helps break the cycle of pain and muscle spasm.

In the second phase of adhesive capsulitis, pain also appears in the neck muscles and the muscles around the shoulder blade. If the patient reports no progress even after 16 weeks, or even gets worse, surgery is considered. This includes closed manipulation of the joint, or arthroscopic manipulation with release of the joint capsule and synovectomy. Passive mobilisation and intensive physiotherapy start immediately after the procedure.

Developing or discovering a substance that could prevent synovitis, and with it the fibrosis and scarring of the joint capsule, would make surgical treatment unnecessary.