Frozen Shoulder

What is a frozen shoulder?

Frozen shoulder, also known as adhesive capsulitis, causes shoulder pain and stiffness, making shoulder mobilizations very difficult over time. It occurs in about 2% of the general population and commonly affects people between the ages of 40 and 60, occurring more in women than in men.

The shoulder joint capsule provides stability and some elasticity during mobilizations. In frozen shoulder this structure becomes thickened and retracted, often presented with fibrous bands (adhesions). The causes of this pathology are not well known. There is no clear relationship with the dominant hand or professional activity. It is known that some factors can lead to an increased risk of developing the disease, namely:

  • Diabetes mellitus: Frozen shoulder occurs much more often in people with diabetes, affecting about 10 to 20% of these patients; The reason remains unknown.
  • Other diseases: Other medical problems associated with frozen shoulder include hypo or hyperthyroidism, Parkinson's disease or heart disease.
  • Immobilization of the shoulder or other shoulder disorders: these conditions can lead to frozen shoulder, so early joint mobilization following trauma or surgical procedures is important.



What are the symptoms of frozen shoulder?

The frozen shoulder usually manifests as pain of slow and progressive installation and develops over two to three years, going through three stages:


  1. Freezing stage (2 to 9 months): pain initially in certain positions with progressive aggravation, particularly at night.
  2. Frozen stage (11 to 12 months): pain reduction with important decrease in mobilities, in particular external rotation.
  3. Thawing stage (6 to 9 months): gradual return of mobility and pain decrease.



How is the diagnosis made?

The diagnosis is clinical, that is, based on the adequate collection of data provided by the patient and the physical examination performed by the physician. This examination will consist of assessing the limitations of mobility and the pain caused by mobilization. The physician will compare the passive mobilities (without force performed by the patient and with the clinician's help) with the active mobilities (performed by the patient, unassisted) - on the frozen shoulder are both diminished.

Other complementary diagnostic tests are not usually performed unless other associated causes of shoulder pain are identified and may also be causing this shoulder stiffness.


What are the therapeutic options?

Frozen shoulder usually resolves spontaneously within 3 years. The focus of treatment is essentially pain control, analgesic and anti-inflammatory medication, and restoration of mobilities and strength through physical therapy cycles. More than 90% of patients respond to this therapeutic approach, although a minority does not regain the extremes of range of  motion. 

Usually, intra-articular corticosteroid therapy is not indicated. If the symptoms do not ease with medication and physical therapy or if the patient appears anxious to resume normal activity, the doctor may discuss the possibility of surgery with the patient. It is important to discuss the patient's potential for spontaneous recovery or non-surgical treatments, given the risks of surgery.

The goal of frozen shoulder surgery is to loosen and release the retracted joint capsule. The most common procedures are manipulation under anesthesia and arthroscopy of the shoulder:

  • Manupulation under anesthesia: during this procedure the patient is sedated and the surgeon forces the shoulder to mobilize, causing the capsule to rupture intentionally. This releases the retraction and increases mobilities.
  • Shoulder arthroscopy: In this procedure small incisions will be performed and with support of the arthroscopic camera and appropriate instruments, portions of the capsule will be released.

In many cases, these two procedures are performed in association for maximum results.

Most patients have very good results with these procedures.


How is postoperative rehabilitation performed?

The postoperative recovery also includes physiotherapy, which can take from six weeks to three months until complete recovery. Commitment to the patient in physical therapy is the most important factor in getting back to normal activities. Long-term results are generally good with most patients without pain or with mild pain and considerable increase in mobilities. However in some cases, even after several years mobilities may not return to normal completely.

Although uncommon, the frozen shoulder may recur, particularly if there is a predisposing factor, such as the presence of diabetes.