Summary

Frozen Shoulder (Adhesive Capsulitis) is a self-limiting but debilitating condition characterized by spontaneous pain and global restriction of glenohumeral movement. It is caused by chronic inflammation and fibrosis of the joint capsule, particularly the Rotator Interval (Coracohumeral Ligament contraction). It is strongly associated with Diabetes and follows a predictable clinical course of three phases: Freezing (Painful), Frozen (Stiff), and Thawing (Recovery). The condition typically resolves over 18-24 months. Management is focused on pain relief and gentle mobilisation; forceful physio in the inflammatory phase makes it worse. [1,2]

Key Facts

• Definition: Global restriction of Active AND Passive range of motion (ROM) in the absence of osteoarthritis.
• Key Sign: Loss of External Rotation (with arm at side) is pathognomonic.
• Epidemiology: Women aged 40-60.
• Diabetes: Increases risk 5-fold. 20% of diabetics get it.
• Duration: The "2-Year Sentence".
• Prognosis: Good. Most regain functional ROM, though some stiffness may persist. Recurrence in the same shoulder is rare, but risk to the other shoulder is 20-30%.

Clinical Pearls

"Active = Passive": This is the golden rule. In Rotator Cuff tears, the patient can't lift the arm (Active loss) but you can lift it for them (Passive preserved). In Frozen Shoulder, neither of you can move it. The joint is glued.

"Don't Push the Freezing Phase": In Phase 1 (Freezing), the shoulder is acutely inflamed (synovitis). Aggressive physio stretching here is torture and makes the inflammation flare. Treat with steroid/rest. Stretch later in Phase 2.

"Rule out the Trap": A locked posterior dislocation presents exactly like a frozen shoulder (fixed internal rotation). ALWAYS X-ray (Axillary view) to check the joint is located.

"The Diabetic Course": Diabetic frozen shoulders are more aggressive, more painful, and less responsive to treatment. Managing expectations is crucial.

         SHOULDER PAIN + STIFFNESS
         (Global Restriction A=P)
                    ↓
             X-RAY (NORMAL)
                    ↓
            FROZEN SHOULDER
                    ↓
        WHICH PHASE ARE THEY IN?
        ┌───────────┴───────────┐
     FREEZING                FROZEN
(Pain Dominant)          (Stiffness Dominant)
        ↓                       ↓
   PAIN CONTROL            MOBILISATION
 - Intra-articular Steroid  - Physiotherapy
 - Hydrodilatation          - Manual Glides
 - Activity Mod             - Hydrodilatation
        ↓                       ↓
    Wait it out             STUCK? (>12m)
                            CONSIDER SURGERY
                           (Capsular Release)

1. Conservative (Benign Neglect)

• Concept: It gets better eventually. Reassurance is a powerful drug here.
• Success: 90% resolve with time and home exercises.
• Physio: Gentle ROM within pain limits. Pulleys, Pendulums.

2. Injection Therapy

• Corticosteroid: Reduces synovitis. Very effective for pain in the Freezing phase.
• Hydrodilatation (Distension):
  • Injecting a large volume (20-40ml) of saline + steroid under pressure.
  • Goal: To physically stretch or rupture the tight capsule.
  • Outcomes: Good evidence for short term pain relief and ROM improvement.

3. Surgical Intervention

• Indication: Failure to progress after 6-12 months of conservative care. Intractable pain.
• Manipulation Under Anaesthesia (MUA):
  • Forcing the arm through the ROM to tear the capsule while asleep.
  • Risk: Spiral fracture of the humerus (osteoporotic bone). Axillary nerve injury.
• Arthroscopic Capsular Release (ACR): (Gold Standard)
  • Keyhole surgery.
  • Using a radiofrequency probe to cut the Rotator Interval and Inferior Capsule (360 degree release).
  • Immediate physio post-op is critical.

Performed under Ultrasound guidance.

1. Entry: Posterior approach usually.
2. Cocktail: 40mg Triamcinolone + 10ml Lidocaine + 20-30ml Saline.
3. Pressure: Inject until resistance is felt, then push more.
4. Endpoint: Often a "pop" is felt (capsule rupture) or fluid backflow prevents further injection.
5. Post-Op: Immediate physiotherapy to maintain the volume gain.

Key Studies

1. UK FROST Trial (Lancet 2020): Large RCT comparing Physio vs MUA vs Arthroscopic Release.
   • Result: NO clinically significant difference between the three groups at 1 year.
   • Implication: Supports conservative management/Hydrodilatation first. Surgery reserved for non-responders.
2. Reeves (1975): Described the natural history (long term follow up).

Guidelines

• BESS (British Elbow & Shoulder Society): Recommend Hydrodilatation as an intermediate step before surgery.

Why is it called Frozen Shoulder?

Because the lining of the joint shrinks and tightens like shrink-wrap plastic. It glues the ball to the socket.

Did I do something to cause it?

Probably not. It often just happens, especially if you have diabetes or thyroid issues. It is a chemical process in the lining, not an injury.

How long will it last?

I have to be honest: it is a long haul. It usually takes 18 months to 2 years to fully resolve. Start-up pain lasts months, then stiffness takes over.

Can you fix it?

We can help the pain with injections. We can stretch it with fluid (Hydrodilatation). Surgery is an option but it's aggressive and most people get better without it if they are patient.