Thursday, June 4, 2009

Frozen shoulder- A mini review


Frozen shoulder or adhesive capsulitis describes the common shoulder condition characterized by painful and limited active and passive range of motion (1). Adhesive capsulitisis is controversial by definition and diagnostic criteria that are not sufficiently understood. Substantial disability and significant morbidity can result from shoulder disorders (2). Idiopathic adhesive capsulitis is a commonly recognized but poorly understood cause of a painful and stiff shoulder (3). According to prevalence reports (2), shoulder disorders have been reported to range from seven to 36% of the population (Lundberg 1969).

The clinical course of this condition is considered self-limiting and is divided into three clinical phases (6). Symptoms in adhesive capsulitis can last up to 2 years (5) and longer even up to 30 months (7). The diagnosis is primarily clinical and no significant changes are normally present at MRI or CT scan (7). Most treatments are conservative; however, indications for surgery do exist (5).

Etiological classification:

The etiology of frozen shoulder remains unclear; however, patients typically demonstrate a characteristic history, clinical presentation, and recovery. A classification schema is described, in which primary frozen shoulder and idiopathic adhesive capsulitis are considered identical and not associated with a systemic condition or history of injury. Secondary frozen shoulder is defined by 3 subcategories: systemic, extrinsic, and intrinsic.

Classification based severity of symptoms:

We also propose another classification system based on the patient's irritability level (low, moderate, and high), that we believe is helpful when making clinical decisions regarding rehabilitation intervention.

Interventions (Nonoperative) in frozen shoulder:

Levine & colleagues (4) found no significant difference for success of nonoperative treatment versus operative treatment or patient gender. Hence the topic of discussion mostly around the evidence successful modalities in frozen shoulder.

Kelley & colleagues have proposed a rehabilitation model based on evidence and intervention strategies matched with irritability levels.
1. Exercise and manual techniques are progressed as the patient's irritability reduces. Response to treatment is based on significant pain relief, improved satisfaction, and return of functional motion.
2. Patients who do not respond or worsen should be referred for an intra-articular corticosteroid injection.
3. Patients who have recalcitrant symptoms and disabling pain may respond to either standard or translational manipulation under anesthesia or arthroscopic release.

Hannafin & colleagues have discussed treatment modality “benign neglect” in frozen shoulder (8). While research reveals that there is no role of NSAIDs in management of adhesive capsulitis Dudkiewicz & colleagues have found, conservative treatment (physical therapy and NSAIDs) is a good long-term treatment regimen for idiopathic adhesive capsulitis (6).

However, common nonoperative interventions include patient education, modalities, stretching exercises, joint mobilization, and corticosteroid injections. Glenohumeral intra-articular corticosteroid injections, exercise, and joint mobilization all result in improved short- and long-term outcomes (1).

With supervised treatment, most patients with adhesive capsulitis experience resolution with nonoperative measures in a relatively short period. Only a small percentage of patients eventually require operative treatment (4).

Physiotherapy & corticosteroids are complimentary

There is strong evidence that glenohumeral intra-articular corticosteroid injections have a significantly greater 4- to 6-week beneficial effect compared to other forms of treatment (1). However, acording to Carette & colleagues reported a single intraarticular injection of corticosteroid administered under fluoroscopy combined with a simple home exercise program is effective in improving shoulder pain and disability in patients with adhesive capsulitis. Adding supervised physiotherapy provides faster improvement in shoulder range of motion. However their study revealed, when used alone, supervised physiotherapy is of limited efficacy in the management of adhesive capsulitis (9).

Out come of physiotherapy interventions for shoulder pain & stiffness:

Physiotherapy is often the first line of management for shoulder pain. Green & colleagues reviewed (CINAHL; 1996-2002) the efficacy of physiotherapy interventions for disorders resulting in pain, stiffness and/or disability of the shoulder. The diagnostic sub groups ware rotator cuff disease, adhesive capsulitis, anterior instability etc (2). However there is an existence of a clinical entity called mixed diagnosis; in which more than one clinical condition mentioned above are present. We have extracted the main points in the context of adhesive capsulitis:

1. There is no evidence that physiotherapy alone is of benefit for Adhesive Capsulitis
2. Laser therapy is said to demonstrate to be more effective than placebo for adhesive capsulitis.
3. There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis.
4. When compared to exercises, ultrasound is of no additional benefit over and above exercise alone for shoulder pain.

Outcome of a stretching regimen in frozen shoulder:

Griggs & colleagues (3) examined the outcome of patients with idiopathic adhesive capsulitis who were treated with a stretching-exercise program.
Phase-II idiopathic adhesive capsulitis were treated with use of a specific four-direction shoulder-stretching exercise program and evaluated prospectively. The vast majority of patients who have phase-II idiopathic adhesive capsulitis are successfully treated with a specific four-direction shoulder-stretching exercise program. More aggressive treatment such as manipulation or capsular release was rarely necessary (3). In this study Griggs & colleagues have revealed that male gender and diabetes mellitus were associated with worse motion outcomes.

Patient satisfaction in physiotherapy treatment:

Griggs & colleagues (3) in their study have revealed: 90 % patients report of a satisfactory outcome with physiotherapy. 10 % are not satisfied with the outcome and 7 % requiring manipulation and/or arthroscopic capsular release. (* patients ware evaluated by Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire; and completion of the Short Form-36 (SF-36) Health Survey)


1. Kelley MJ et al; J Orthop Sports Phys Ther. 2009 Feb;39(2):135-48.
2. Green S et al; Cochrane Database Syst Rev. 2003;(2):CD004258.
3. Griggs SM et al; J Bone Joint Surg Am. 2000 Oct;82-A(10):1398-407.
4. Levine WN et al; J Shoulder Elbow Surg. 2007 Sep-Oct;16(5):569-73. Epub 2007 May 24.
5. Tasto JP et al; Sports Med Arthrosc. 2007 Dec;15(4):216-21.
6. Dudkiewicz I et al; Isr Med Assoc J. 2004 Sep;6(9):524-6.
7. Brue S et al; Knee Surg Sports Traumatol Arthrosc. 2007 Aug;15(8):1048-54. Epub 2007 Feb 28.
8. Hannafin JA et al; Clin Orthop Relat Res. 2000 Mar;(372):95-109.
9. Carette S et al; Arthritis Rheum. 2003 Mar;48(3):829-38.

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