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Adhesive Capsulitis (Frozen Shoulder) Treatment & Management

  • Author: Albert W Pearsall, IV, MD; Chief Editor: S Ashfaq Hasan, MD  more...
 
Updated: Dec 28, 2015
 

Medical Therapy

Idiopathic adhesive capsulitis affecting the glenohumeral joint is believed to be self-limiting and is often treated effectively with physical therapy and medications. However, studies on the natural history of the condition have noted long-term pain in many patients who receive nonoperative treatment, with as many as 10% of patients never fully recovering normal shoulder activities.[28, 29]

Various authors have reported an inflammatory component to frozen shoulder syndrome, especialy early in the course of the disease. Therefore, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful in patients with relatively new-onset symptoms. With diminished inflammation and pain, the patient is better able to tolerate physical therapy. Before prescribing any medication, however, the clinician should query the patient about any contraindications to NSAIDs.

NSAIDs have not been demonstrated to be of great efficacy in individuals who present with prolonged symptoms. Oral corticosteroids can be prescribed in lieu of NSAIDs, as they provide a stronger anti-inflammatory effect. Either NSAIDs or corticosteroids may be used in conjunction with a subacromial corticosteroid injection.[30, 31] The use of low-dose oral corticosteroids is recommended only in cases of severe refractory frozen shoulder that has either been present for an extended period (ie, longer than 2 mo) or is causing significant pain.[11, 32, 33] Although oral corticosteroids provide significant short-term benefits, the effect may not be maintained beyond 6 weeks.[34]

Due to the potential side effects of corticosteroids, the patient should be thoroughly questioned regarding past medical history, including diabetes mellitus. Diabetes mellitus is not an absolute contraindication to the use of oral corticosteroids; however, because of the potential hyperglycemic effects of corticosteroids, it should be used judiciously and the patient's blood glucose should be closely monitored.  

Oral steroids are typically given in a 3-week tapered course of prednisone, although treatment may range from 2-6 weeks.[34] See Table 1, below.

 

Table 1. (Open Table in a new window)

Corticosteroid Dosing in Patients With Refractive Frozen Shoulder Syndrome*
Week Number Medication Dose
1 (Days 1-7) Prednisone 40 mg/d
2 (Days 8-14) Prednisone 30 mg/d
3 (Days 15-18) Prednisone 20 mg/d
4 (Days 19-21) Prednisone 10 mg/d
5 (Days 22+) Discontinue ----
*Before oral corticosteroid medication is prescribed, the patient should be extensively questioned about pertinent medical problems that may be contraindications to taking the medicine.

Because adhesive capsulitis is rare in children, NSAIDs and corticosteroids are rarely are used in this population. Most pediatric patients respond to conservative physical therapy without the use of medications.

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Surgical Therapy

A subgroup of patients with frozen shoulder syndrome often fail to improve despite treatment with aggressive nonsurgical therapy and medication. These patients frequently are referred to as having a refractory or recalcitrant frozen shoulder. Specifically, these patients demonstrate minimal improvement in shoulder pain and motion over a 3-month period, despite the use of aggressive nonoperative measures, including medications and physical therapy. In these refractory cases, more invasive techniques (eg, manipulation, distention arthrography, open surgical release) may be needed.

Although several authors have championed the success of these therapies, significant complications, ranging from humeral shaft fractures, to rotator cuff tears and transient brachial plexus injuries have been reported with closed manipulation. Ogilvie-Harris and Warner have demonstrated the efficacy of arthroscopic capsular release for the refractory frozen shoulder.[35, 36, 37] Based on these reports and work by others, a selective arthroscopic capsular release is recommended for patients with refractory frozen shoulder.[38]

Once the patient is under anesthesia a detailed preoperative assessment of the affected and unaffected shoulder's passive range of motion (PROM) is performed. Typically there is global loss of motion in the affected shoulder with the contracture affecting the entire capsule. Standard arthroscopic shoulder portals are established. Based on the preoperative examination, the glenohumeral joint capsule is released with electrocautery, as seen in the image below. Typically a circumferential capsular release is performed. Care is taken to avopid any release of the intra-articular subscapularis tendon. Before the patient is taken from the operating room, the individual's ROM is documented and compared with his or her presurgical motion. With 24-48 hours of postoperative pain relief provided by a preoperative interscalene block, ROM exercises should be initiated on the day of surgery. An interscalene catheter can be placed when performing the interscalene block to allow for an extended period of pain relief. A 2-week course of oral corticosteroids also should be initiated on the day of surgery.

True anteroposterior view of the glenohumeral join True anteroposterior view of the glenohumeral joint (left); axillary lateral view (middle); supraspinatus outlet view (right)

Ahn et al developed an ultrasound-guided interventional release of the rotator interval using a round needle designed specifically for this procedure. All 13 patients experienced significant improvement.[39]

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Postoperative Details

Further inpatient care is indicated only in refractory patients. Patients receiving arthroscopic or open capsular release frequently are in the hospital for several days to permit interscalene anesthesia and aggressive, monitored physical therapy. However, patients rarely have to return to the hospital following the initial surgery. A small group of patients with adhesive capsulitis relapse, despite surgical intervention and physical therapy; admitting these patients for interscalene anesthesia and aggressive physical therapy may be appropriate.

Most patients with adhesive capsulitis use either an anti-inflammatory medication or a short course of an oral corticosteroid. Occasionally, patients may require medication for pain. A chronic-pain medication such as gabapentin (Neurontin) or amitriptyline is preferred for these symptoms.

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Follow-up

Patients with adhesive capsulitis—those who have been treated with conservative therapy and those who have had surgical intervention—should be closely monitored as outpatients. Usually, supervised or home physical therapy is a component of treatment. In addition, the patient may be taking oral corticosteroids, which must be monitored for side effects. The patient should be monitored every several weeks to document progress.

The patient should be monitored at 2-week intervals for the first month after surgery. Thereafter, follow-up intervals can be increased from 6 weeks to 3 months, as needed.

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Complications

The predominant complication arising from adhesive capsulitis is residual shoulder stiffness or pain. Several reports have indicated that most patients may continue to have pain and/or stiffness for up to 3 years following conservative treatment. In addition, humeral fracture, biceps tendon rupture, and subscapularis tendon rupture have been reported after shoulder manipulation.

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Outcome and Prognosis

In the past, frozen shoulder was considered a self-limiting condition that could be treated with physical therapy and would resolve in 1-3 years. However, several studies have demonstrated long-term pain and shoulder stiffness following conservative treatment.

Several studies have noted improved symptoms following arthroscopic capsular release. Warner and colleagues reported an improvement in the Constant and Murley score of 48 points with a mean follow-up of 39 months.[40] Pearsall and colleagues found that 83% of patients reported their shoulder to be normal or near normal at an average of 22 months following capsular release.[41] Ogilvie-Harris noted that 15 of 18 patients treated with arthroscopic capsular release had an excellent result at 2-5 years following surgery. A review of the literature indicates that in patients with refractory adhesive capsulitis, a near-excellent to excellent result of 75-90% can be expected with arthroscopic capsular release and an aggressive postoperative physical therapy regimen.

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Future and Controversies

Hyperthyroidism, ischemic heart disease, diabetes mellitus,[11] and cervical spondylosis have been associated with the occurrence of adhesive capsulitis. Patients with these conditions should be alerted to the increased risk of developing frozen shoulder.

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Contributor Information and Disclosures
Author

Albert W Pearsall, IV, MD Associate Professor, Department of Orthopedic Surgery, University of South Alabama College of Medicine; Director, Section of Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, University of South Alabama Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

S Ashfaq Hasan, MD Associate Professor, Chief, Shoulder and Elbow Service, Department of Orthopaedics, University of Maryland School of Medicine

S Ashfaq Hasan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Shoulder and Elbow Surgeons

Disclosure: Nothing to disclose.

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True anteroposterior view of the glenohumeral joint (left); axillary lateral view (middle); supraspinatus outlet view (right)
Table 1.
Corticosteroid Dosing in Patients With Refractive Frozen Shoulder Syndrome*
Week Number Medication Dose
1 (Days 1-7) Prednisone 40 mg/d
2 (Days 8-14) Prednisone 30 mg/d
3 (Days 15-18) Prednisone 20 mg/d
4 (Days 19-21) Prednisone 10 mg/d
5 (Days 22+) Discontinue ----
*Before oral corticosteroid medication is prescribed, the patient should be extensively questioned about pertinent medical problems that may be contraindications to taking the medicine.
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