Consultant Internal Medicine Dr Vivek Baliga reviews a common medical problem - frozen shoulder. It is simple to treat but carries a significant morbidity if ignored. Aimed at medical students.

1. Frozen Shoulder - A Review
Dr Vivek Baliga
Consultant Physician
Baliga Diagnostics

2. What Is Frozen Shoulder?
● Also called adhesive capsulitis
● Clinical condition where the movement of the shoulder becomes
restricted
● Range from mild restriction all the way to severe restriction
accompanied by a great deal of pain
● First recorded case of frozen shoulder was described in 1872 by
Duplay in this article on ‘periarthritis scapulohumeral’.
● The term ‘frozen shoulder’ was coined by Codman in 1934.

3. Incidence Of Frozen Shoulder
● 3 to 5% incidence of frozen shoulder in the general population.
● Those who have diabetes can have up to a 20% incidence
● One of the most common clinical conditions encountered by
orthopaedic surgeons.
● Typical patient who has frozen shoulder is a woman between the age
of 50 to 70 years

4. Associated Conditions
● Diabetes mellitus
● Hyperthyroidism
● Hypothyroidism
● Heart disease (cardiovascular disease)
● Tuberculosis
● Parkinson’s Disease
● Stroke - Immobility
● History of injury to the arm - tears, fractures etc.

5. Classification
● Primary Frozen Shoulder
○ Idiopathic frozen shoulder is insidious in onset
● Secondary frozen shoulder
○ Follows trauma or injury to the shoulder joint and subsequent
requirement for immobilisation.

6. Clinical Stages
Freezing or Painful
stage
● Mild restriction of the
shoulder joint
● Patients may not
necessarily seek
medical attention.
Frozen or Transitional
stage
● Pain remains constant
● Range of movement of
the shoulder joint
becomes limited
● Lasts between 4 to 12
months
Thawing stage
● Range of
movement
returns to
normal gradually
over a 12 to 42
month period.

7. Symptoms
● Gradual onset shoulder pain
● Inability to lift the arm up beyond a certain point - abduction
and external rotation becomes painful
● Discomfort localised to the area of insertion of deltoid muscle
● Inability to sleep on the affected side
● Normal shoulder x-ray

8. Diagnosis
A diagnosis of frozen shoulder is often made clinically. X-rays may not
necessarily be helpful.
Blood tests may determine other associated conditions.
There is usually no specific need for an MRI scan as a clinical diagnosis is
often sufficient.

9. Treatment
● Non-Operative
● Operative

10. Non-Operative Treatment
● Non-steroidal anti-inflammatory drugs can help relieve pain to an extent and remain the
first choice of treatment.
○ They do not change the natural course of the disease.
● Intra-articular corticosteroid injections
○ There may be some short-term benefit.
○ Subacromial or glenohumeral approach is considered
● Exercise Therapy
○ Aim behind exercise therapy is to prevent a further reduction in the range of
movement of the shoulder joint.
○ Exercises include passive mobilisation and capsular stretching.

11. Surgical Treatment
● Surgical treatment is only recommended in those individuals who
have not seen any difference in their symptoms following at least 2
months of nonsurgical therapies.
● Manipulation under anaesthesia
○ Individual is placed under anaesthesia and the shoulder joint is
manipulated so as to loosen the tissues and allow full range of
movement.
● Arthroscopic release and repair
○ The tightened coracohumeral ligament and contracted capsule
can be loosened and released

12. Conclusion
● Frozen shoulder is a common condition that carries a significant
morbidity.
● Treatments revolve around non-surgical methods in combination with
steroid agents.
● However, a small number of patients will require surgical release of
the shoulder capsule for complete benefit.
References
Uppal HS, Evans JP, Smith C. Frozen shoulder: A systematic review of therapeutic options. World Journal of
Orthopedics. 2015;6(2):263-268. doi:10.5312/wjo.v6.i2.263.