Issue 15 December 2004
General points
- Frozen shoulder is characterised by the gradual onset of pain, often with unknown aetiology, and global restriction of active and passive movement
- Effective analgesia is required to manage pain
- In the painful phase consider intra-articular corticosteroid injection, which should be administered by an experienced clinician
- Exercise will exacerbate pain in the acute phase but a simple home exercise programme can be initiated as acute pain settles. If there is a poor response, consider referral for supervised exercise
- Other treatment options that may be of benefit are laser therapy and acupuncture plus exercise
- Manage patients’ expectations by explaining the natural history of this condition; advise it may take up to twoyears to resolve.
Background
True frozen shoulder (adhesive capsulitis) is more common in women than men and typically presents between the ages of40 and 60years. There is a higher incidence in people with diabetes. In these people it is usually present at a younger age, is typically less painful and does not respond as well to treatment. The recommendations for the diagnosis and management of frozen shoulder, summarised below, are based on the recent ACC Guideline on the Diagnosis and Management of Soft Tissue Shoulder Injuries.1
Diagnosis
Frozen shoulder is characterised by gradual and spontaneous onset of pain and global restriction of movement of the glenohumeral joint. Pain can be severe, especially at night. Patients report substantial functional limitation with activities of daily living such as dressing and reaching [4]. Diagnosis is based on the history and clinical examination and has been described as a “clinical diagnosis of exclusion” [4]. The aetiology is typically unknown. However, there can be a history of minor trauma and occasionally significant injury. The stiffness experienced with frozen shoulder is the key clinical feature differentiating frozen shoulder from rotator cuff disorders.
Three Phases of Clinical Presentation
Painful: This phase lasts 2-3months and is characterised by aching pain and global restriction of movement. Pain at rest and at night, causing disturbed sleep, are key features. Function can be severely compromised.
Stiff: Stiffness is the predominant feature, lasting between3 and 12months. The shoulder is comfortable within a restricted range of movement and at rest.
Resolving: There is a gradual gain in range of movement with less discomfort, lasting a further6-12 months. Although there may be residual minor restriction of range of movement, people do not report functional limitation.
Investigations
X-ray, ultrasound and blood tests are not routinely required except where necessary to rule out other pathology.
Management
A detailed explanation at the outset of the natural history of the condition is important to help manage patient expectations. In patients with a history of injury, early mobilisation is important.
Analgesics
Effective analgesia is required to manage pain. Adjust pain relief according to pain severity and individual patient needs.
Intra-articular corticosteroid injection
There is good evidence that this has a therapeutic effect in the early painful phase, compared with placebo [1++] or physiotherapy [1+]. Injections should be administered intra-articularly by an experienced clinician, and require a strict aseptic technique. Fluoroscopic guidance can be useful especially for obese patients. In general, one injection is all that is required, with no more than three in the same joint per annum. Obtain and document informed consent and discuss potential adverse effects. See related ACC Reviews.2
Exercise
Avoid exercise in the painful phase, as it will exacerbate pain. When acute pain subsides, simple home exercise may be helpful but there is evidence that supervised exercise may lead to faster recovery of the range of movement [1+]. Mobilisation plus exercise has not been found to be more effective than exercise alone [1++].
Other therapies
Laser therapy may be beneficial [1++] and acupuncture plus exercise compared with exercise alone, may achieve better outcomes [1+]. There is good evidence that hydrodilation (joint distension with saline solution) is not effective [1++].
Timing
The optimal timing of therapies, other than steroid injection and avoiding exercise in the painful phase, is yet to be determined.
Summary
Gradual onset of pain and global restriction of movement characterise frozen shoulder, with a return to normal function taking up to 2years. Effective analgesia is required to manage pain. In the painful phase, limits on exercise are required and an intra-articular corticosteroid injection may have a therapeutic effect (see discussion above). Supervised exercise, laser therapy and exercise plus acupuncture are treatment options. Optimal timing of these therapies is yet to be determined. It is important to explain the natural history of the condition to patients to manage expectations.
References
- New Zealand Guidelines Group. The Diagnosis and Management of Soft Tissue Shoulder Injuries and Related Disorders. Accident Compensation Corporation, Wellington, 2004. See www.acc.co.nz and www.nzgg.org.nz
- ACC Review: Rotator Cuff Disorders – Management (Issue14, Nov 2004) and ACC Review: Corticosteroid Injections in Shoulders (Issue 6, Dec 2003).
Evidence Scale
Adapted Scottish Intercollegiate Guidelines Network (SIGN) Grading System – as used in the guideline.
Evidence is graded according to the quality of the study or studies from which it was drawn.
1++ Meta-analysis (MA)/systematic reviews (SR) of randomised controlled trials (RCTs) with a very low risk of bias
1+ MA/SR of RCTs with a low risk of bias
1- MA/SR of RCTs with a high risk of bias
2++ SR of case-control/cohort studies with a low risk of bias/moderate probability of causal relationship
2+ Case-control/cohort studies with a low risk of bias/moderate probability of causal relationship
2- Case-control/cohort studies with a high risk of bias/significant risk of non-causal relationship
3 Non-analytic studies
4 Expert opinion (from the literature or the multidisciplinary NZ guideline team)