Approach Considerations
The goals of treatment for frozen shoulder syndrome (FSS) are to relieve pain and restore movement and shoulder function. FSS is self-limiting; long-term outcomes are essentially the same, regardless of the treatment used. [41, 22]
Physiotherapy and home exercise are first-line treatments for all stages of FSS. [12, 52] These are often combined with anti-inflammatory medications and glenohumeral joint corticosteroid injection. [53]
Most patients with adhesive capsulitis are treated nonoperatively; more than 90% respond to conservative interventions to control pain and restore motion. Invasive options for refractory cases include extracorporeal shockwave therapy, manipulation under anesthesia, hydrodilatation (hydrodistention), and selective arthroscopic capsular release.
Medical Therapy
Idiopathic adhesive capsulitis affecting the glenohumeral joint is believed to be self-limiting and is often treated effectively with physical therapy and anti-inflammatory 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. [31, 54]
Nonsteroidal anti-inflammatory drugs
Various authors have reported an inflammatory component to frozen shoulder syndrome, especially early in the course of the disease. Therefore, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful in patients with recent-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 demonstrated great efficacy in individuals who present with prolonged symptoms. They have not been shown to improve pain or function compared with placebo. [12]
Oral glucocorticoids
Oral corticosteroids can be prescribed in lieu of NSAIDs, as they provide a stronger anti-inflammatory effect, however they should not be given routinely due to their potential adverse effects. 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 months) or is causing significant pain. [13, 55, 56] Although oral corticosteroids provide significant short-term benefits, the effect may not be maintained beyond 6 weeks. [57]
Due to the potential adverse 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, but given the potential hyperglycemic effects of corticosteroids, these agents 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. [57] See Table 3, below.
Table 3. Prednisone Dosing in Patients With Refractory Frozen Shoulder Syndrome (Open Table in a new window)
Week |
Dose |
|
1 (Days 1-7) |
40 mg/d |
|
2 (Days 8-14) |
30 mg/d |
|
3 (Days 15-18) |
20 mg/d |
|
4 (Days 19-21) |
10 mg/d |
|
5 (Days 22) |
Discontinue |
|
Note: 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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Corticosteroid injections
A local corticosteroid injection can be used in conjunction with oral NSAIDs or oral corticosteroids. [58, 59] Studies have shown 20 mg triamcinolone as an optimal dose. [22] The corticosteroid may be combined with a local anesthetic (eg, lidocaine). Intra-articular or subacromial injections have equal efficacy. [60] Corticosteroid injections provide rapid relief that typically lasts for 6 weeks. Long-term outcomes are similar to those with placebo. [34]
A randomized trial that compared ultrasound (US)-guided injection with blind injection found that by the second week postinjection, improvement in pain intensity, range of motion, and shoulder function score was significantly greater in the US-guided injection group than in the blind injection group. Beyond the third week, however, there were no further significant differences in the improvement between the 2 groups. [61]
Adverse effects must be considered. Triamcinolonone injections can result in Cushing syndrome in patients on protease inhibitors (ritonavir/norvir). Administer injections with caution in patients who have diabetes. [62]
Extracorporeal Shockwave Therapy
Extracorporeal shockwave therapy (ESWT) shows promise as a therapy for adhesive capsulitis. [63] ESWT compared favorably with oral steroids as a short-term treatment for primary adhesive capsulitis in a prospective, randomized, controlled, single-blind clinical trial by Chen et al in 40 patients. From the fourth week of treatment, the ESWT group showed significant improvement superior to that in the steroid group; at the sixth week, improvement in activities of daily living (ADL) achieved significance and was better than that in the steroid group. [64]
Results of an observational study by Santoboni and colleagues suggest that ESWT may offer a safer alternative to steroid injections or surgery for treatment of adhesive capsulitis in patients with diabetes. In their study, which included 50 consecutive patients with an overall mean pain duration of 15.7 months, significant functional improvements compared with baseline were evident at 2 months, with further amelioration at 4 and 6 months. [65]
All patients received ESWT once a week for 3 weeks, with 2400 shots in an anterior-to-posterior direction on the anterior shoulder joint using a low/moderate-energy flux density (0.06–0.14 mJ/mm2, depending on individual pain tolerance). No relevant adverse effects were reported. [65]
Surgical Therapy
A subgroup of patients with frozen shoulder syndrome 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 under anesthesia, hydrodilatation, surgical release) may be needed.
Manipulation under anesthesia
Manipulation of frozen shoulders under general anesthesia is intended to rupture the contracted capsule, and in some studies it has been shown to accelerate healing. [66] This technique has been combined with other modalities, including local corticosteroid injection, hydrodistention, [67] and limited capsular release. [68] Significant complications have been reported, however, ranging from humeral shaft fractures to rotator cuff tears and transient brachial plexus injuries. [66]
Hydrodilatation
Hydrodilatation (also termed hydrodistention and distention arthrography) involves the ultrasound-guided injection of a large volume of saline—typically along with a corticosteroid, local anesthetic, and contrast medium—into the joint space. [66] The therapeutic effect of hydrodilatation was initially attributed to rupture of the capsule, but capsular distention may in fact be the mechanism. [66]
Studies of hydrodilatation have yielded conflicting results, especially with regard to patients with diabetes mellitus. For example, a systematic review and meta-analysis concluded that hydrodilatation has only a small, clinically insignificant effect on adhesive capsulitis. [69] On the other hand, the largest single study, in 109 shoulders, concluded that hydrodilatation is effective, although patients with severe cases and those with diabetes tended to respond less well in the long term. [70] A study of 90 patients who underwent hydrodilatation after failure of initial treatment that included physiotherapy and at least one corticosteroid injection reported clinically important improvements in pain and function that remained clearly substantial at 24 weeks. [71]
Arthroscopic capsular release
Ogilvie-Harris et al and Warner et al have demonstrated the efficacy of arthroscopic capsular release for the refractory frozen shoulder. [72, 73, 74] Based on these reports and work by others, a selective arthroscopic capsular release is recommended for patients with refractory frozen shoulder. [75]
Once the patient is under anesthesia, a detailed preoperative assessment of the affected and unaffected shoulder's passive ROM is performed. Typically the affected shoulder exhibits global loss of motion, 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. 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. [76] Care is taken to avoid any release of the intra-articular subscapularis tendon. Before the patient is taken from the operating room, the shoulder ROM is documented and compared with the presurgical ROM.
True anteroposterior view of the glenohumeral joint (left); axillary lateral view (middle); supraspinatus outlet view (right)
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.
A review by Miyazaki et al of surgical treatment in 56 shoulders with FSS concluded that that inferior capsulotomy yields the best results. In addition, these authors reported lower reoperation rates in patients who receive interscalene catheter anesthetic infusion for postoperative rehabilitation. [77]
Postoperative Details
Further inpatient care is indicated only in refractory patients. Patients receiving arthroscopic or open capsular release frequently remain 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 number 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 or amitriptyline is preferred for these symptoms.
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, and so require monitoring for adverse effects. The patient should be assessed every several weeks to document progress.
The patient should be seen 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.
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.
Outcome and Prognosis
FSS has a favorable natural history. It is generally a self-limiting condition that can be treated with physical therapy and typically resolves in 1-3 years. [38] Time to recovery does not differ between primary and secondary FSS. No difference in pain and disability of FSS in patients with and without diabetes has been reported. [39] Patients with FSS do not have a lower shoulder activity level than sex- and age-matched controls. [40]
However, several studies have demonstrated long-term pain and shoulder stiffness following conservative treatment. Long-term disability has been reported in 15%, [8] permanent functional loss in 7-15%, and persistent symptoms in 40%. [41]
Several studies have noted improved symptoms following arthroscopic capsular release, as follows:
-
Warner and colleagues reported an improvement in the Constant and Murley score of 48 points with a mean follow-up of 39 months. [78]
-
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. [79]
-
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 in 75-90% of cases can be expected in patients treated with arthroscopic capsular release and an aggressive postoperative physical therapy regimen.
Future and Controversies
Possible alternative treatments for frozen shoulder syndrome (FSS) include the following:
-
A randomized controlled double-blind study of acupuncture (using press tack needles) integrated with conservative therapy in 60 patients with primary FSS reported immediate pain reduction; subsequently, classical needle acupuncture treatments over 10 weeks produced faster improvement in pain compared with conservative therapy only. [82] This approach may be beneficial in the early painful stages of the disease.
-
In a randomized study in 29 patients with early FSS that compared the efficacy of different intra-articular injections, the combination of a low-dose corticosteroid (triamcinolone, 20 mg) with hyaluronidase (1 mL) proved superior to that of low-dose corticosteroid alone and equivalent to that of high-dose corticosteroid (triamcinolone, 40 mg). [86]
-
Collagenase clostridium histolyticum (CCH) is an injection treatment that is approved by the US Food and Drug Administration for Dupuytren contracture in adult patients with a palpable cord. An early trial in patients with FSS found that extra-articular injections of CCH were well tolerated and effective compared with exercise. [87] In a subsequent trial, however, CCH injection failed to provide a statistically significant improvement in function, and the authors recommended against its use for FSS, in view of its adverse effects and potential risks. [88]
Long-Term Monitoring
Any of the following instruments can be used for long-term monitoring:
-
Shoulder Pain and Disability Index (SPADI)
-
Simple Shoulder Test (STT)
-
Constant-Murley Shoulder Score (CMS)
-
Oxford Shoulder Score (OSS)
-
Visual Analogue Scale (VAS)
-
UCLA shoulder scale
-
True anteroposterior view of the glenohumeral joint (left); axillary lateral view (middle); supraspinatus outlet view (right)
Tables
| Stage | Duration |
|---|---|
| Stage 1 Freezing (painful) | Up to 9 months |
| Stage 2 Frozen (stiffening) | 4 months - 20 months |
| Stage 3 Thawing | 5 months- 26 months |
| Contralateral shoulder | 6 months - 7 years after initial onset of symptoms |
| Stage | Joint capsular thickness (mm) in humeral portion of the axillary access | Joint capsule edema in humeral portion of axillary recess | Obliteration of subcoracoid fat triangle |
|---|---|---|---|
| 1 | 4.67 | 97% | 74% |
| 2 | 3.73 | 83% | 56% |
| 3 | 3.67 | 64% | 21% |
Week |
Dose |
|
1 (Days 1-7) |
40 mg/d |
|
2 (Days 8-14) |
30 mg/d |
|
3 (Days 15-18) |
20 mg/d |
|
4 (Days 19-21) |
10 mg/d |
|
5 (Days 22) |
Discontinue |
|
Note: Before oral corticosteroid medication is prescribed, the patient should be extensively questioned about pertinent medical problems that may be contraindications to taking the medicine. |
||
