Frozen shoulder (adhesive capsulitis)
- Tore A Prestgaard, MD
Tore A Prestgaard, MD
- Department of Neurology, Rheumatology and Rehabilitation, Drammen Hospital, Norway
- Board Member of the Scandinavian Foundation of Medicine and Science in Sports
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Frozen shoulder has been defined by the American Academy of Orthopedic Surgeons as: "A condition of varying severity characterized by the gradual development of global limitation of active and passive shoulder motion where radiographic findings other than osteopenia are absent." The condition is also characterized by severe shoulder pain.
Frozen shoulder is also referred to as adhesive capsulitis, painful stiff shoulder, and periarthritis. We will use the term "frozen shoulder" throughout this review. This topic will review the diagnosis and management of frozen shoulder. Evaluation of the patient with undifferentiated shoulder pain and other specific causes of shoulder pain or dysfunction are discussed separately. (See "Evaluation of the patient with shoulder complaints" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears".)
The prevalence of frozen shoulder is estimated to be 2 to 5 percent of the general population [1,2]. The condition is most common in the fifth and sixth decades of life, with the peak age in the mid-50s. Onset before the age of 40 is rare. Women are more often affected than men. The non-dominant shoulder is slightly more likely to be affected. In 6 to 17 percent of patients, the other shoulder becomes affected within five years .
Frozen shoulder occurs predominantly unilaterally and is usually self-limited, although evidence about prognosis is limited, and the course can be prolonged, in some cases lasting over two to three years [4,5]. Some studies suggest that up to 40 percent of patients have persistent but mostly mild symptoms beyond three years, and 15 percent have long-term disability [6-10].
ETIOLOGY AND PATHOPHYSIOLOGY
Frozen shoulder can be primary (or idiopathic) but is often associated with other diseases and conditions. Patients with diabetes mellitus are at greater risk of developing frozen shoulder, with a prevalence of 10 to 20 percent [1,11-13]. The condition has also been associated with thyroid disease [14,15], prolonged immobilization, stroke, autoimmune disease, and in rare instances with Parkinson disease  and antiretroviral therapy (particularly protease inhibitors) for HIV infection [17-19].
- Morén-Hybbinette I, Moritz U, Scherstén B. The clinical picture of the painful diabetic shoulder--natural history, social consequences and analysis of concomitant hand syndrome. Acta Med Scand 1987; 221:73.
- Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975; 4:193.
- Rizk TE, Pinals RS. Frozen shoulder. Semin Arthritis Rheum 1982; 11:440.
- Grey RG. The natural history of "idiopathic" frozen shoulder. J Bone Joint Surg Am 1978; 60:564.
- Wong CK, Levine WN, Deo K, et al. Natural history of frozen shoulder: fact or fiction? A systematic review. Physiotherapy 2017; 103:40.
- SIMMONDS FA. Shoulder pain with particular reference to the frozen shoulder. J Bone Joint Surg Br 1949; 31B:426.
- Binder AI, Bulgen DY, Hazleman BL, Roberts S. Frozen shoulder: a long-term prospective study. Ann Rheum Dis 1984; 43:361.
- Hazleman BL. The painful stiff shoulder. Rheumatol Phys Med 1972; 11:413.
- Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg 2008; 17:231.
- Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term follow-up. J Bone Joint Surg Am 1992; 74:738.
- Lequesne M, Dang N, Bensasson M, Mery C. Increased association of diabetes mellitus with capsulitis of the shoulder and shoulder-hand syndrome. Scand J Rheumatol 1977; 6:53.
- Pal B, Anderson J, Dick WC, Griffiths ID. Limitation of joint mobility and shoulder capsulitis in insulin- and non-insulin-dependent diabetes mellitus. Br J Rheumatol 1986; 25:147.
- Huang YP, Fann CY, Chiu YH, et al. Association of diabetes mellitus with the risk of developing adhesive capsulitis of the shoulder: a longitudinal population-based followup study. Arthritis Care Res (Hoboken) 2013; 65:1197.
- Wohlgethan JR. Frozen shoulder in hyperthyroidism. Arthritis Rheum 1987; 30:936.
- Bowman CA, Jeffcoate WJ, Pattrick M, Doherty M. Bilateral adhesive capsulitis, oligoarthritis and proximal myopathy as presentation of hypothyroidism. Br J Rheumatol 1988; 27:62.
- Riley D, Lang AE, Blair RD, et al. Frozen shoulder and other shoulder disturbances in Parkinson's disease. J Neurol Neurosurg Psychiatry 1989; 52:63.
- Zabraniecki L, Doub A, Mularczyk M, et al. Frozen shoulder: a new delayed complication of protease inhibitor therapy? . Rev Rhum Engl Ed 1998; 65:72.
- Peyriere H, Mauboussin JM, Rouanet I, et al. Frozen shoulder in HIV patients treated with indinavir: report of three cases. AIDS 1999; 13:2305.
- Grasland A, Ziza JM, Raguin G, et al. Adhesive capsulitis of shoulder and treatment with protease inhibitors in patients with human immunodeficiency virus infection: report of 8 cases. J Rheumatol 2000; 27:2642.
- Evans JP, Guyver PM, Smith CD. Frozen shoulder after simple arthroscopic shoulder procedures: What is the risk? Bone Joint J 2015; 97-B:963.
- Bruckner FE, Nye CJ. A prospective study of adhesive capsulitis of the shoulder ("frozen shoulder') in a high risk population. Q J Med 1981; 50:191.
- Ozaki J, Nakagawa Y, Sakurai G, Tamai S. Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J Bone Joint Surg Am 1989; 71:1511.
- Neviaser TJ. Adhesive capsulitis. Orthop Clin North Am 1987; 18:439.
- Bunker TD, Anthony PP. The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br 1995; 77:677.
- Müller LP, Müller LA, Happ J, Kerschbaumer F. Frozen shoulder: a sympathetic dystrophy? Arch Orthop Trauma Surg 2000; 120:84.
- Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder: a chronic inflammation mast cell mediated proliferative fibrosis. 2005 SECEC/ESSSE meeting Rome; 2005 Sep 21-24: Rome, Italy.
- Kalichman L, Ratmansky M. Underlying pathology and associated factors of hemiplegic shoulder pain. Am J Phys Med Rehabil 2011; 90:768.
- Bianchi, S, Martinoli, C. Shoulder. In: Ultrasound of the musculoskeletal system, Bianchi, S, Martinoli, C (Eds), Berlin, Heidelberg 2007. p.287.
- Ryu KN, Lee SW, Rhee YG, Lim JH. Adhesive capsulitis of the shoulder joint: usefulness of dynamic sonography. J Ultrasound Med 1993; 12:445.
- Maund E, Craig D, Suekarran S, et al. Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Health Technol Assess 2012; 16:1.
- Favejee MM, Huisstede BM, Koes BW. Frozen shoulder: the effectiveness of conservative and surgical interventions--systematic review. Br J Sports Med 2011; 45:49.
- Page MJ, Green S, Kramer S, et al. Manual therapy and exercise for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev 2014; :CD011275.
- Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. J Shoulder Elbow Surg 2004; 13:499.
- Buchbinder R, Green S, Youd JM, Johnston RV. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev 2006; :CD006189.
- Buchbinder R, Hoving JL, Green S, et al. Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial. Ann Rheum Dis 2004; 63:1460.
- Lorbach O, Anagnostakos K, Scherf C, et al. Nonoperative management of adhesive capsulitis of the shoulder: oral cortisone application versus intra-articular cortisone injections. J Shoulder Elbow Surg 2010; 19:172.
- Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003; :CD004016.
- Prestgaard T, Wormgoor ME, Haugen S, et al. Ultrasound-guided intra-articular and rotator interval corticosteroid injections in adhesive capsulitis of the shoulder: a double-blind, sham-controlled randomized study. Pain 2015; 156:1683.
- Ranalletta M, Rossi LA, Bongiovanni SL, et al. Corticosteroid Injections Accelerate Pain Relief and Recovery of Function Compared With Oral NSAIDs in Patients With Adhesive Capsulitis: A Randomized Controlled Trial. Am J Sports Med 2016; 44:474.
- Xiao RC, Walley KC, DeAngelis JP, Ramappa AJ. Corticosteroid Injections for Adhesive Capsulitis: A Review. Clin J Sport Med 2017; 27:308.
- de Jong BA, Dahmen R, Hogeweg JA, Marti RK. Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens. Clin Rehabil 1998; 12:211.
- Yoon SH, Lee HY, Lee HJ, Kwack KS. Optimal dose of intra-articular corticosteroids for adhesive capsulitis: a randomized, triple-blind, placebo-controlled trial. Am J Sports Med 2013; 41:1133.
- Shah N, Lewis M. Shoulder adhesive capsulitis: systematic review of randomised trials using multiple corticosteroid injections. Br J Gen Pract 2007; 57:662.
- Jones A, Regan M, Ledingham J, et al. Importance of placement of intra-articular steroid injections. BMJ 1993; 307:1329.
- Sibbitt WL Jr, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol 2009; 36:1892.
- Eustace JA, Brophy DP, Gibney RP, et al. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 1997; 56:59.
- Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004; 31:308.
- Bloom JE, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database Syst Rev 2012; :CD009147.
- Lee HJ, Lim KB, Kim DY, Lee KT. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. Arch Phys Med Rehabil 2009; 90:1997.
- Carette S, Moffet H, Tardif J, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum 2003; 48:829.
- Buchbinder R, Green S, Youd JM, et al. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev 2008; :CD007005.
- Mun SW, Baek CH. Clinical efficacy of hydrodistention with joint manipulation under interscalene block compared with intra-articular corticosteroid injection for frozen shoulder: a prospective randomized controlled study. J Shoulder Elbow Surg 2016; 25:1937.
- Tveitå EK, Tariq R, Sesseng S, et al. Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC Musculoskelet Disord 2008; 9:53.
- Jacobs LG, Barton MA, Wallace WA, et al. Intra-articular distension and steroids in the management of capsulitis of the shoulder. BMJ 1991; 302:1498.
- Corbeil V, Dussault RG, Leduc BE, Fleury J. [Adhesive capsulitis of the shoulder: a comparative study of arthrography with intra-articular corticotherapy and with or without capsular distension]. Can Assoc Radiol J 1992; 43:127.
- Gam AN, Schydlowsky P, Rossel I, et al. Treatment of "frozen shoulder" with distension and glucorticoid compared with glucorticoid alone. A randomised controlled trial. Scand J Rheumatol 1998; 27:425.
- Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev 2003; :CD004258.
- Page MJ, Green S, Kramer S, et al. Electrotherapy modalities for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev 2014; :CD011324.
- Rill BK, Fleckenstein CM, Levy MS, et al. Predictors of outcome after nonoperative and operative treatment of adhesive capsulitis. Am J Sports Med 2011; 39:567.
- Hamdan TA, Al-Essa KA. Manipulation under anaesthesia for the treatment of frozen shoulder. Int Orthop 2003; 27:107.
- Wang JP, Huang TF, Hung SC, et al. Comparison of idiopathic, post-trauma and post-surgery frozen shoulder after manipulation under anesthesia. Int Orthop 2007; 31:333.
- Berghs BM, Sole-Molins X, Bunker TD. Arthroscopic release of adhesive capsulitis. J Shoulder Elbow Surg 2004; 13:180.
- ETIOLOGY AND PATHOPHYSIOLOGY
- CLINICAL PRESENTATION
- EXAMINATION AND DIAGNOSTIC TESTING
- Physical examination
- Injection test
- - Plain radiography
- - Magnetic resonance imaging
- - Musculoskeletal ultrasound
- DIFFERENTIAL DIAGNOSIS
- General approach to management
- Physical therapy
- Oral corticosteroids
- Glucocorticoid injection
- - Effectiveness
- - Accuracy of intra-articular injections
- Glucocorticoid injections combined with physical therapy
- Intra-articular dilation (distension)
- Other interventions
- Referral and surgery
- FOLLOW UP
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS