Adhesive capsulitis

Frozen Shoulder: Concept, Diagnosis, and Treatment Options

The first recorded description of frozen shoulder was published by Duplay in 1872, who described it as scapulohumeral periarthritis, although it wasn't until 1934 that Codman used the term frozen shoulder.

Frozen shoulder, also known as adhesive capsulitis or retractile capsulitis, is a condition of unknown cause that causes progressive pain and stiffness in the shoulder, significantly limiting its function.
Frozen shoulder occurs in approximately 2–5% of the population. It is more common in women and in the 40–60 age group.

There is some association with cardiovascular disease, thyroid disease, diabetes mellitus (more severe forms of presentation and with a worse prognosis), and Dupuytren's disease. Shoulder immobilization periods due to fractures, bruises, or other causes can be the onset of the condition, so it is always recommended to mobilize the shoulder under medical supervision to avoid this situation.

It is common for the other shoulder to be affected some time after the first shoulder is affected.

It can be primary, idiopathic (i.e., without a known cause), or secondary to bruises, fractures, or even surgery.

Description

In frozen shoulder, a chronic inflammatory process develops that stimulates the formation of adhesions and fibrosis of the shoulder capsule, which thickens and hardens.
Four stages of the disease have been described:

• Stage 1 (pre-adhesive): The predominant symptom is pain. There is inflammation, and the formation of rigid bands of tissue, adhesions, begins. The patient has full mobility, and the condition is often indistinguishable from other conditions such as tendon ruptures, bursitis, or calcific tendonitis. This stage can last up to 3 months.
• Stage 2 (adhesive): In this stage, pain remains the most prominent symptom, with the onset of progressive loss of mobility, with difficulty performing certain activities such as dressing, combing hair, fastening a bra, or reaching your back pocket. This stage can last 3 to 6 months.
• Stage 3 (frozen shoulder): In this stage, inflammation decreases and fibrosis increases. The pain may improve, but the stiffness worsens, and shoulder mobility is reduced. This stage can last 3 to 6 months.
• Stage 4 (thawing): The patient gradually regains mobility, and the pain is mild. It can last a year or more.

Diagnosis

The physical examination in the initial stages will show pain upon movement with possible decreased mobility, a condition often indistinguishable from other shoulder pathologies, as previously discussed.
During the freezing phase, the pain will decrease, and shoulder movement, both active (performed by the patient) and passive (performed by the physician), will be drastically reduced.
Plain X-rays will not be useful for diagnosing frozen shoulder, but they will rule out other shoulder pathologies with similar symptoms.
Ultrasound can rule out tendon ruptures, bursitis, joint effusions, tendon calcifications, among other problems, and is a helpful test, just as X-rays can help rule out other shoulder problems.
Magnetic resonance imaging and, above all, arthral resonance (MRI with prior injection of contrast into the joint) can confirm the capsular thickening and adhesions present in frozen shoulder.

Non-surgical Treatment

As we have previously explained, frozen shoulder usually progresses slowly but favorably, so conservative treatment is recommended initially. These include:

• Anti-inflammatory treatment (NSAIDs and corticosteroids)
• Rehabilitation/physical therapy
• Corticosteroid injections
• Percutaneous hydrodistension

Many published articles support these treatments for treating frozen shoulder. Some of them compare these treatments individually or in combination, and extrapolate results.

Below, we briefly explain these treatments:

• Anti-inflammatory treatment with NSAIDs or oral corticosteroids will help control pain in the initial stages. They usually have a short-term effect and are not without side effects, so they should be taken for short periods of time and under medical supervision. They can help make RHB sessions more bearable during the frozen shoulder phase.
• Rehabilitation and physical therapy are the first-line and almost universal treatment. They will help prevent the loss of shoulder mobility in the early stages and help restore it during the frozen phase. The most commonly used techniques are passive mobility and capsular stretching. We can combine shock waves, electromagnetic stimulation, or acupuncture with physical therapy.
• Corticosteroid injections are another widely used therapy, although their effect will be short-term (around 6 weeks) and will improve pain but not stiffness. Combined with physical therapy, we can be more aggressive with physical therapy and shorten recovery times.
• Percutaneous hydrodistension, first described by Andren, consists of the intra-articular introduction of large volumes of fluid (up to 40-50 cc) with the aim of distending the joint capsule and eliminating adhesions and neovascularization that have formed in the frozen shoulder to restore lost mobility. It can be performed under CT radiological control (both emit ionizing radiation and therefore irradiate the patient and require an operating room or radiology suite) or under ultrasound control (accessible in the office and without emission of ionizing radiation). Subject to multiple comparative studies to evaluate its effectiveness with other types of treatments, it is considered useful in improving the range of motion, improving its effectiveness associated with intra-articular corticosteroids (Gam et al, 1998; Courveil et al, 1992; Tveita et al, 2008), physiotherapy (Khan et al, 2005) or even surpassing other procedures such as mobilization under general anesthesia (Quraishi et al, 2007).

Surgical Treatment

The goal of surgery for frozen shoulder is to stretch and release the joint capsule that has become rigid. The most common methods include manipulation under anesthesia and shoulder arthroscopy.

• Mobilization under general anesthesia involves subjecting the patient to general anesthesia and mobilizing the shoulder in all planes. This technique is not without risks, such as fractures, rotator cuff tears, or nerve injuries (brachial plexus).
• Arthroscopic capsular release aims to release the joint capsule that has become rigid. Some surgeons combine mobilization with arthroscopic release.

Make an appointment with Dr. Jordi Jiménez. He will see you in the center of Palma and help you regain your quality of life.