Frozen Shoulder is one the commonest disorders of the shoulder characterised by pain and stiffness.

1. Frozen Shoulder
Dr Milind Merchant
Arthroscopy Surgeon
Mumbai

2. • “ clinical condition wherein the patient has
restricted active and passive gleno-humeral
motion for which no other cause can be
identified (X-rays to be normal)”

3. • Duplay
– “periarthrite scapulohumerale”(1872)
• Codman
– “difficult to define, difficult to treat and difficult to
explain”
– “uncalcified tendonitis”
• Nevasier “adhesive capsulitis”

4. Pathology
• Chronic inflammation
• Perivascular infiltration
• Myo-fibroblastic proliferation
– “Dupuytren’s disease”
• Rarely subacromial bursitis

5. • Autoimmune causes
• Trigger points with myofascial pain syndrome
• Local periarticular hypoxia

6. Incidence
• Age: 40-70 years
• 2-5% in non-diabetics
• 10-20% in diabetics

7. Types and stages of frozen shoulder:
• Primary or idiopathic (20% bilateralism)
– Three stages:
• Painful phase (2-9months)
• Stiffening phase (4-12 months)
• Thawing phase 6-24 months)
• Secondary
– ST injury, fractures or cuff tears

8. • Period of immobility
– Overuse, whiplash, neck problems or minor trauma
– “periarthritic personality”
• “peculiar emotional constitution, unable to tolerate pain,
expected others to get them well and refused to take any
initiative in their recovery”
• Major trauma
• Cervical disc disease
• Hypothyroidism
• Intra-cranial pathology
• Intra-thoracic disorders

9. • Location of Pathology:
– “rotator interval” (SGHL, MGHL & CHL)
– Circumferential capsular contracture with
obliteration of recesses
– Adherence of biceps and cuff to capsule

10. Capsular Contracture

11. • “several studies have reported ongoing
symptoms for upto 10 years after onset of
frozen shoulder”

12. Investigations:
• Plain X-Rays
– AP in scapular plane
– Axillary
• ? MRI scan (only if cuff tear suspected)
• ? arthrography

13. Examination findings
• Neck examination
• Cuff and deltoid disuse
• Restricted ROM
– Active and passive block
– Reduced ER

14. Range of motion

15. Treatment:
• Painful phase:
– Rest, analgesia, heat or ice, TENS
– Gleno-humeral steroid injections
– NO MANIPULATION OR STRETCHING EXERSICES

16. Stiffening and Thawing phase:
• Manipulation and steroid injection:
• Indications:
– Failure of conservative management
– Should comply with physiotherapy regime
– Aware of risks
• Contraindications:
– Secondary frozen shoulders after dislocations or
fractures
– Osteopenic bones
– Poor post-operative co-operation

17. • “Sustained improvement in shoulder function
was observed for upto 15 years after
manipulation”
– Cofield et al (JSES, 2005)

18. Arthroscopic arthrolysis:
• Under GA & ISB
• Examine the anatomy
• Release adhesions from cuff and biceps
• Arthroscopic release of rotator interval
– SGHL, MGHL and CHL
• Release posterior capsule
• MUA to break the anterior band IGHL
• Explore sub-acromial space
• GH steroid injection & post operative
physiotherapy