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Frozen shoulder (adhesive capsulitis)

Frozen shoulder (adhesive capsulitis)
Literature review current through: Jan 2024.
This topic last updated: Feb 21, 2023.

INTRODUCTION — Frozen shoulder has been defined by the American Academy of Orthopedic Surgeons as "a condition of varying severity characterized by the gradual development of global limitation of active and passive shoulder motion where radiographic findings other than osteopenia are absent." The condition is also characterized by severe shoulder pain.

Frozen shoulder is also referred to as adhesive capsulitis, painful stiff shoulder, and periarthritis. We will use the term "frozen shoulder" throughout this review. This topic will review the diagnosis and management of frozen shoulder. Evaluation of the patient with undifferentiated shoulder pain and other specific causes of shoulder pain or dysfunction are discussed separately. (See "Evaluation of the adult with shoulder complaints" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears".)

EPIDEMIOLOGY — The lifetime prevalence of frozen shoulder is estimated to be 2 to 5 percent of the general population [1-3]. In a questionnaire study of 9696 randomly selected adults, frozen shoulder was found to affect 8.2 percent of men and 10.1 percent of women of working age [4]. The condition is most common in the fifth and sixth decades of life, with the peak age in the mid-50s. Onset before the age of 40 is rare. Women are more often affected than men. The non-dominant shoulder is involved slightly more often. In 6 to 17 percent of patients, the other shoulder becomes affected within five years [5].

Frozen shoulder occurs predominantly unilaterally and is usually self-limited, although evidence about prognosis is limited, and the course can be prolonged, in some cases lasting over two to three years [6,7]. Some studies suggest that up to 40 percent of patients have persistent but mostly mild symptoms beyond three years, and 15 percent have long-term disability [8-12]. Patients with type 1 diabetes often have a more prolonged course and are more resistant to therapy [13,14].

ETIOLOGY AND PATHOPHYSIOLOGY — Frozen shoulder can be primary (or idiopathic) but is often associated with other diseases and conditions. Patients with diabetes mellitus are at greater risk of developing frozen shoulder. In a meta-analysis of six case-control studies, diabetics were found to be over three times more likely to develop adhesive capsulitis [15], while the overall prevalence among diabetics is reported to be 10 to 20 percent [1,3,16-18]. Prevalence among long-term diabetics may be even higher. A cross-sectional study reported the point prevalence of frozen shoulder in patients with long-lasting type 1 diabetes to be as high as 59 percent, with a lifetime prevalence 76 percent [13].

The condition has also been associated with thyroid disease [19,20], dyslipidemia [21], prolonged immobilization, stroke, autoimmune disease, and in rare instances with Parkinson disease [22] and antiretroviral therapy (particularly protease inhibitors) for HIV infection [23-25]. Thyroid disorders, particularly hypothyroidism and benign thyroid nodules, may increase the risk for frozen shoulder as much as 2.7 times [26]. Genetic predisposition may play a role in developing frozen shoulder [27].

Frozen shoulder also occurs as a secondary problem after shoulder injuries, such as rotator cuff tears, proximal humerus fractures, or shoulder surgery [28]. It has been reported subsequent to other surgical procedures, such as cardiac surgery and neurosurgery [29]. Early mobilization of the shoulder joint following surgery is felt to be an important preventative measure, but data are lacking.

The pathophysiology of frozen shoulder is not fully understood. A common hypothesis is based upon arthroscopic observations that inflammation occurs initially, especially in and around the axillary fold of the joint capsule, the anterosuperior joint capsule, the coracohumeral ligament, and the rotator cuff interval [30], followed by the development of adhesions and fibrosis of the synovial lining [31]. Preliminary studies suggest the pathophysiology of frozen shoulder differs between the upper and lower parts of the joint capsule [32]. In part, the process involves thickening and contraction of the glenohumeral joint capsule and the collagenous tissue surrounding the joint, thereby markedly reducing joint volume.

Despite these observations, disagreement exists about whether the underlying pathologic process is primarily an inflammatory or fibrosing condition [33], or perhaps even an algoneurodystrophic process (ie, related to sympathetic dystrophy or complex regional pain syndrome [CRPS]) [34,35]. (See "Complex regional pain syndrome in adults: Pathogenesis, clinical manifestations, and diagnosis".)

In the case of stroke, the pathologic condition may differ from idiopathic frozen shoulder: stiffness may result from muscle spasticity and glenohumeral subluxation [36].

CLINICAL PRESENTATION — Frozen shoulder is commonly described as progressing through three phases:

First, an initial, painful phase with development of diffuse, severe, and disabling shoulder pain that is worse at night, and increasing stiffness that lasts for two to nine months.

Second, an intermediate phase with stiffness and severe loss of shoulder motion, but with pain becoming gradually less pronounced, that lasts for 4 to 12 months.

Finally, a recovery phase with a gradual return of range of motion that takes from 5 to 24 months to complete [2,6].

Typical for patients with frozen shoulder are complaints of severe, nagging pain at night and progressive global stiffness of the shoulder, with significant disability restricting activities of daily living, work, and leisure [2,31]. Later in the course, as stiffness and severe loss of shoulder motion come to predominate, pain persists, particularly at the outer limits of shoulder movement. The varying degrees of impaired function associated with frozen shoulder can include limited reaching (eg, overhead, to the side, across the chest) and limited rotation (eg, unable to scratch the back, put on a coat).

Although there are few formal studies of factors that might affect the stages described above, our clinical experience is that the duration of these stages is consistent among the range of causes of frozen shoulder. In other words, the time needed for recovery does not differ substantially between patients with idiopathic or post-traumatic frozen shoulder, or among patients with diabetes, stroke, or other associated medical conditions. Concomitant conditions, such as degenerative disc disease of the cervical spine, can cause discomfort, but they do not appear to influence the duration of symptoms associated with frozen shoulder.

EXAMINATION AND DIAGNOSTIC TESTING

Physical examination — A stiff and painful glenohumeral joint makes it difficult to perform a complete shoulder examination. Nevertheless, patients with frozen shoulder usually demonstrate significant reductions in active and passive range of motion in two or more planes compared with their unaffected shoulder. In most cases, external rotation and abduction are the movements most affected. Patients with frozen shoulder often demonstrate difficulties placing their hand on their back or buttock. The shoulder examination is described in detail separately. (See "Physical examination of the shoulder".)

In patients with frozen shoulder, there is normally less pain with isometric testing of shoulder strength. Typically, there is also a firm, painful, and premature end to passive range of motion in a frozen shoulder. This limitation in motion is a true mechanical restriction, rather than a pain-related limitation.

The following photographs of a patient with frozen shoulder show common examination findings associated with the condition. Note the differences in motion between the affected left shoulder and the normal right shoulder (picture 1).

Injection test — An injection test may be helpful in establishing the diagnosis if, following a careful history and physical examination, the clinician continues to have difficulty distinguishing between frozen shoulder and subacromial conditions. In patients with frozen shoulder, active movement restriction and the palpable, painful end detected with passive motion testing persist after injection of an anesthetic into the subacromial (but extra-articular) space. In contrast, patients with pain from focal subacromial pathology (eg, rotator cuff tendinopathy, subacromial bursitis) generally experience pain relief and improved range of motion. The injection can easily be performed with or without ultrasound guidance and is described separately. (See "Evaluation of the adult with shoulder complaints", section on 'Injection tests'.)

Imaging

Plain radiography — Plain radiographs are of limited diagnostic use in patients with frozen shoulder; most often the plain film is normal, except for osteopenia in some cases. Nevertheless, it is reasonable to obtain routine shoulder radiographs (including posteroanterior, external rotation, Y-outlet, and axillary views) in patients with suspected frozen shoulder to exclude other disorders, such as glenohumeral osteoarthritis, which may present with similar symptoms and clinical findings. (See "Clinical manifestations and diagnosis of osteoarthritis", section on 'Shoulder'.)

Magnetic resonance imaging — Magnetic resonance imaging (MRI) studies are usually not necessary to make the diagnosis of frozen shoulder in patients with a typical history and physical examination, and no evidence of other pathology. However, in diagnostically challenging cases (eg, patients with concomitant glenohumeral osteoarthritis, persistent active rotator cuff tendinopathy, or neurologic deficits affecting the shoulder girdle), MRI or MR arthrography can be helpful.

In frozen shoulder, MRI typically shows [37]:

Enhancement of rotator cuff interval

Enhancement of axillary joint capsule

Hyperintensity of inferior glenohumeral ligament

Thickening of inferior glenohumeral ligament

Each of these findings is reported to demonstrate sensitivity of approximately 90 percent and specificity of approximately 80 percent. Additional changes that may be present include coracohumeral ligament thickening and fat obliteration of the rotator cuff interval.

Musculoskeletal ultrasound — Although there are no specific ultrasound findings for frozen shoulder, a sonographic assessment can be helpful. Findings associated with frozen shoulder may include [38]:

Thickening of the coracohumeral ligament and the soft-tissue structures in the rotator cuff interval (in the early phase)

(The rotator cuff interval is the space between the subscapularis and supraspinatus tendons that contains the long head of the biceps tendon and is used for ultrasound imaging)

Increased fluid in the tendon sheath of the long head of the biceps

Increased vascularity around the intraarticular portion of the biceps tendon and the coracohumeral ligament (requires color Doppler imaging)

Dynamic imaging of patients with frozen shoulder reveals limitations in the sliding movement of the supraspinatus tendon below the acromion during abduction [39]. Ultrasound is also helpful in ruling out pathology of the rotator cuff and bursa.

DIAGNOSIS — The diagnosis of frozen shoulder is suspected in patients complaining predominantly of unilateral shoulder pain and stiffness, either with spontaneous onset without an underlying cause or subsequent to shoulder surgery or injury (eg, rotator cuff tear, proximal humerus fracture). Remember that patients with diabetes mellitus and other systemic diseases are at increased risk. (See 'Etiology and pathophysiology' above.)

Frozen shoulder is a clinical diagnosis made on the basis of the medical history and physical examination. The diagnosis is confirmed by demonstrating reduced range of motion of the glenohumeral joint that is not due to other painful conditions (eg, glenohumeral osteoarthritis, rotator cuff tendinopathy, subacromial bursitis, fractures). No specific test (laboratory or imaging) alone provides the diagnosis. Plain radiograph, ultrasound, and MRI can be used to rule out other conditions and to confirm the likelihood of the correct diagnosis.

DIFFERENTIAL DIAGNOSIS — The early symptoms and signs of frozen shoulder can be confused with subacromial pathology (eg, rotator cuff tendinopathy, subacromial bursitis, impingement syndrome). In all these conditions, patients report pain and limited active range of motion. However, several facets of the clinical presentation and examination help to distinguish frozen shoulder from these conditions. (See "Rotator cuff tendinopathy" and "Subacromial (shoulder) impingement syndrome".)

Patients with subacromial pathology often give an occupational or athletic history of heavy lifting or repetitive movements, especially above shoulder level. Patients with rotator cuff tendinopathy and subacromial bursitis often complain of activity-related pain and problems performing usual activities. In some cases, symptoms may occur in the non-dominant arm and in non-manual workers.

Limitations in shoulder motion are more often due to pain in patients with subacromial pathology, as opposed to the mechanical restrictions found with frozen shoulder, particularly in its later stages. In contrast, patients with a painful subacromial condition demonstrate limited active range of motion while passive range of motion is preserved.

Although frozen shoulder may be preceded by a history of subacromial symptoms, patients are just as likely to describe a spontaneous onset without an apparent cause or a history of overuse or abnormal activity. Frozen shoulder can develop following shoulder injuries, surgery, or prolonged immobilization for any reason. Patients with frozen shoulder often complain of chronic, severe, nagging pain deep in the shoulder (ie, glenohumeral) joint, especially at night, and of progressive global stiffness of the shoulder that severely restricts activities of daily living, work, and leisure [2,31].

Age is another distinguishing factor. Frozen shoulder is unlikely in patients younger than 40 years of age, and patients older than 70 are more likely to have rotator cuff tears or glenohumeral osteoarthritis.

Later in the course of frozen shoulder, as stiffness and severe loss of motion come to predominate, pain persists, particularly at the outer limits of shoulder movement. The varying degrees of impaired function associated with frozen shoulder include limited reaching (eg, overhead, to the side, across the chest) and limited rotation (eg, unable to scratch the back or put on a jacket).

Other problems that occur less often but are included in the differential diagnoses of frozen shoulder include referred pain from the neck or diaphragm, degenerative disc disease of the cervical spine, myocardial ischemia, polymyalgia rheumatica, and malignancy, particularly apical lung cancers and metastases. Clinicians should pay close attention to any patient with systemic symptoms and signs consistent with cancer, infection, or other chronic illness.

MANAGEMENT

Overview — In most cases, frozen shoulder is a self-limited condition, although complete resolution does not occur in many patients. There is limited high quality evidence to guide treatment and consequently no standard management approach exists. The most comprehensive systematic review to date concluded that there is limited clinical evidence of the effectiveness of treatments in adhesive capsulitis and that high quality clinical trials are needed [40]. Treatment options vary from benign neglect to invasive techniques.

Patient education is important to reduce frustration and ensure compliance with treatment. Acetaminophen and/or nonsteroidal antiinflammatory drugs (NSAIDs) may be used for pain control. However, there are no randomized controlled trials that confirm the effectiveness of NSAIDs in frozen shoulder. Sometimes, particularly in the early phase of the condition, opioid analgesics may be required.

Common nonoperative treatments for frozen shoulder include physical therapy, glucocorticoids given orally or as intraarticular injections, with or without hydrodilatation.

General approach to management — Although the treatment of frozen shoulder must be modified based upon patient characteristics and goals, we generally use the following approach:

Initial evaluation:

Obtain a good history. Confirm the diagnosis by demonstrating reduced range of motion of the glenohumeral joint that is not due to other painful conditions. Be certain the cervical spine is not involved. (See 'Clinical presentation' above and 'Physical examination' above.)

Obtain plain radiographs of shoulder to rule out other diagnoses as indicated. Perform ultrasound evaluation to rule out rotator cuff pathology. (See 'Imaging' above.)

If the diagnosis is difficult, give a subacromial injection test of anesthetic (eg, one percent lidocaine 5 mL). (See 'Injection test' above.)

We suggest giving an intraarticular glucocorticoid injection for moderate to severe symptoms. If pain is severe, we consider the addition of a suprascapular nerve block. Some clinicians skilled in the procedure may perform intraarticular dilation as part of the initial treatment. (See 'Glucocorticoid injection' below and 'Intraarticular dilatation (distension)' below.)

Next two to three months:

Shoulder rest combined with gentle range of motion exercises for the glenohumeral joint, performed only if they do not cause undue discomfort. Photographs of the exercises are provided in the physical therapy discussion. (See 'Physical therapy' below.)

If little or no improvement at follow-up visits (approximately every three to four weeks): Give intraarticular injection of glucocorticoid. Perform home exercise program as symptoms allow. Video clips of the exercises are provided in the physical therapy discussion. (See 'Physical therapy' below.)

If significant improvement at follow-up visits: Suggest more aggressive exercise regimen to increase glenohumeral range of motion, as pain (or other symptoms) allows.

Following months: Periodically (approximately every two to three months) reassess range of motion and pain. Most often, patients can perform a more strenuous home exercise program. Refer to physical therapist if needed.

Months 10 to 12: Refer to orthopedic surgery if no improvement or severe restrictions in glenohumeral movement persist. If there are any signs of improvement, continue with exercises and/or physical therapy and reassess.

Physical therapy — Although physical therapy is commonly used to treat frozen shoulder, evidence for its effectiveness is limited [41,42]. According to a meta-analysis of 32 trials (most of limited quality) involving 1836 participants, the efficacy of manual therapy or exercise remains unclear, as most studies reported no clinically or statistically significant differences among treatment groups [42]. In fact, one prospective study of 77 patients with idiopathic frozen shoulder reported that exercise performed within the limits of pain led to greater improvements in shoulder function than intensive physical therapy [43]. More aggressive stretching of the shoulder muscles and capsule may only be useful in the later phase of the condition. The addition of supervised physical therapy following an intraarticular injection of glucocorticoid may result in more rapid improvement than injection alone. (See 'Glucocorticoid injections combined with physical therapy' below.)

Patients with mild disease and those early in the recovery phase of frozen shoulder may benefit from performing gentle range of motion exercises (eg, pendulum swings) provided they do not cause undue discomfort. As pain allows, patients can add stretching and strengthening exercises, with or without the supervision of a physical therapist. In our experience, overly aggressive physical therapy performed early in the course of frozen shoulder often produces increased pain with little improvement in shoulder function.

The gentle shoulder motion exercises recommended by the author early in the course of frozen shoulder consist of the following:

Gentle abduction (picture 2)

Gentle external rotation (picture 3)

Gentle internal rotation (picture 4)

Gentle combined abduction and external rotation (picture 5)

Exercises that can be added as shoulder motion begins to improve include those depicted in the video clips below. The author recommends that patients perform these exercises twice daily.

Abduction-adduction with exercise band (movie 1)

Flexion extension with exercise band (movie 2)

Seated external rotation with elbow resting on table (movie 3)

Oral glucocorticoids — A systematic review of several small studies of variable quality found that a short course of oral glucocorticoids can reduce pain and improve mobility in patients with frozen shoulder, but relief generally does not extend beyond a few weeks [44]. As an example, a double-blinded controlled trial of 50 patients reported that a three-week course of prednisolone (30 mg daily) produced significant short-term improvements in shoulder pain and function, but the benefits were not maintained beyond six weeks [45]. We suggest that oral glucocorticoids not be given as a routine treatment for frozen shoulder given their potential adverse effects and the increased effectiveness of intraarticular glucocorticoid injections [46].

Glucocorticoid injection

Effectiveness — Intraarticular glucocorticoid injections appear to be beneficial in the treatment of frozen shoulder, leading to improved range of motion and pain reduction [47-51]. However, the effect is of limited duration [41,47-49,52]. Successful treatment probably depends upon the duration of symptoms: patients who receive injections early in their course are more likely to obtain benefit, possibly due to a reduction of synovitis [10].

Suitable medications for injection include triamcinolone 20 to 40 mg and methylprednisolone 20 to 40 mg. We prefer to dilute the glucocorticoid with a local anesthetic such as lidocaine. (See "Intraarticular and soft tissue injections: What agent(s) to inject and how frequently?", section on 'Use of glucocorticoid injections'.)

One randomized trial reported a trend toward greater improvements in shoulder function and pain at six weeks in patients (n = 25) treated with a 40 mg intraarticular injection of triamcinolone compared to patients (n = 32) injected with 10 mg [53]. Another randomized trial of 53 patients with adhesive capsulitis found no difference in the efficacy of 20 versus 40 mg triamcinolone acetonide [54].

In a systematic review of trials using multiple glucocorticoid injections, there was evidence that up to three injections was beneficial and limited evidence that up to six injections was beneficial [55]. Single versus multiple glucocorticoid injections were not compared in any included study. Adverse reactions included increased pain after injection (10 to 44 percent), facial flushing (12.5 to 20 percent), rash (4 percent), and irregular menstrual bleeding (10.5 percent).

Location and accuracy of injections — Early studies of intraarticular glucocorticoids to treat frozen shoulder primarily involved injections performed using external anatomic landmarks for guidance. Sonographic guidance for intraarticular injections is being used more frequently. Ultrasound-guided intraarticular injections may improve the effectiveness of this treatment for frozen shoulder. Further randomized trials to test this hypothesis are needed, as are studies of alternative injection sites. Pending the results of such studies, we suggest using intraarticular injections. (See 'General approach to management' above.)

In a randomized trial of intraarticular injections performed by experienced musculoskeletal clinicians (orthopedists and rheumatologists), unintended extra-articular injections occurred in as many as 50 to 60 percent of the procedures performed without ultrasound guidance [56]. While some studies have concluded that such inaccurate injections are less effective at reducing pain and improving function [57-59], a systematic review found no evidence of added benefit from sonographic-guided compared to landmark-guided injections for shoulder pain [60]. However, only four trials considered in this review included patients with adhesive capsulitis, and one small trial concluded that ultrasound guided injections may offer short-term advantages over blind technique for the treatment of adhesive capsulitis [61].

Other studies raise questions about the best location for glucocorticoid injection. A randomized trial involving 122 adults with frozen shoulder found no difference in the effectiveness of a combined intraarticular and rotator interval injection compared with an intraarticular injection alone (both injection approaches used ultrasound guidance), but that either approach was superior to a sham injection for providing pain relief up to 12 weeks, as well as improving function and reducing disability [47]. Another randomized trial involving 77 patients with primary frozen shoulder in the freezing stage found that a single glucocorticoid injection into the rotator interval yielded greater improvements in pain, passive range of motion, and function than did an intraarticular or subacromial injection [62].

Glucocorticoid injections combined with physical therapy — Although evidence is limited, the combination of intraarticular glucocorticoid injection followed by physical therapy may be more effective than either therapy alone for frozen shoulder. This was suggested by the results of a trial of 93 patients who were randomly assigned to treatment with glucocorticoid injection followed by physical therapy, glucocorticoid injection alone, saline injection followed by physical therapy, or saline injection (placebo) alone [63]. Patients treated with glucocorticoid injection and physical therapy experienced significantly faster improvements in shoulder function than the other three groups. Of note, physical therapy alone was of limited benefit and by one year there was no discernible difference in improvement among the four groups.

Suprascapular nerve block — The suprascapular nerve provides most of the sensory innervation to the shoulder joint. Thus, a suprascapular nerve block, performed at either the suprascapular or spinoglenoid notch, may reduce the pain associated with early frozen shoulder. In addition, some theorize that the suprascapular nerve may be involved in the pathophysiology of frozen shoulder and that a nerve block may provide additional benefits. Performance of such blocks is discussed separately. (See "Upper extremity nerve blocks: Techniques", section on 'Suprascapular nerve block'.)

A systematic review and meta-analysis of nine preliminary studies reported significant improvements in pain, motion, and overall shoulder function following a suprascapular nerve block [64]. In a randomized trial of 54 patients, those treated with a suprascapular nerve block in addition to glenohumeral injection and physical therapy experienced reduced pain, increased mobility, and a resolution of symptoms six months sooner than patients treated with glenohumeral injection and physical therapy alone [65].

Intraarticular dilatation (distension) — Another treatment for frozen shoulder is to combine intraarticular injection of an anesthetic with an infusion of saline to dilate the glenohumeral capsule (the technique is referred to as hydrodilatation or arthrographic distension). Essentially, saline is injected into the joint under pressure. This technique is based upon the finding that frozen shoulder generally involves thickening and contraction of the glenohumeral joint capsule and the collagenous tissue surrounding the joint, thereby markedly reducing joint volume, which is felt to contribute to diminished glenohumeral motion.

According to a systematic review of five trials including 196 patients, arthrographic distension with saline and glucocorticoid provides short-term benefits in pain reduction, range of motion, and overall shoulder function in patients with frozen shoulder [66]. Subsequent trials have also reported benefit [67], however, further study is needed to determine whether this intervention is superior to alternative treatments.

Although hydrodilatation appears to be an effective short-term treatment when compared with sham injection (ie, arthrography only), it is less certain that capsular distention plus glucocorticoids is superior to glucocorticoid injection alone.

Among the better studies to address this question was a trial in which 76 patients were randomly assigned to treatment with a glucocorticoid injection plus hydrodilatation or glucocorticoid injection alone, with injections given under fluoroscopic guidance at two-week intervals over a six-week period [68]. The authors found no significant difference between groups in the degree of improved shoulder function. Other studies comparing treatment with hydrodilatation to glucocorticoid injection alone have noted improvement in both groups without significant differences in outcomes [69-71].

Other interventions — Some studies of treatments for painful shoulder or frozen shoulder include claims that laser therapy provides short-term relief of pain from adhesive capsulitis [41,72]. However, the studies cited to support this claim are either outdated and involve patients with rotator cuff "tendinitis," not frozen shoulder, or are methodologically weak. There is no high quality evidence that laser therapy or pulsed electromagnetic field therapy is effective treatment for frozen shoulder [73].

Referral and surgery — Available evidence consisting primarily of observational studies suggests that surgery does not improve the outcome of frozen shoulder in the large majority of patients [74]. We believe that surgical treatment should be reserved for patients who do not respond to conservative management. The referral process should be individualized based upon patient characteristics and goals.

There are no formal guidelines to determine an appropriate timeframe for referral. We think most patients should be managed conservatively for at least 10 to 12 months, as long as they are making progress. A glucocorticoid injection and supervised physical therapy program can be implemented initially, often with satisfying results. With this strategy, only a small percentage of patients will need surgical intervention. Failure of the patient with frozen shoulder to regain full range of motion may stem from underlying comorbidities, such as osteoarthritis of the glenohumeral joint or rotator cuff muscle atrophy, possibly due to a cervical radiculopathy or peripheral nerve pathology.

Surgical intervention consists primarily of manipulation of the glenohumeral joint under anesthesia or arthroscopic release of the glenohumeral joint capsule. Some surgeons perform intraarticular dilation. (See 'Intraarticular dilatation (distension)' above.)

Manipulation of the shoulder has proven to be effective; however, it does not allow for a controlled release of the pathologic tissue restricting motion and carries an increased risk of humerus fracture and intraarticular shoulder injury [75,76]. Arthroscopic release is now more commonly performed. Arthroscopic techniques include the use of bipolar radiofrequency devices to carry out a controlled release of the shoulder capsule [77,78].

In a randomized trial, 503 patients with severe symptoms of frozen shoulder of at least 9 to 10 months in duration were assigned to treatment with manipulation under anesthesia, arthroscopic capsular release (ACR), or structured physiotherapy [79]. Manipulation and ACR were followed by post-procedural physical therapy. Supplemental glucocorticoid injection was given to patients treated with manipulation but was optional in the ACR group. Physical therapy involved mobilization techniques and a graduated home exercise program supplemented by a glucocorticoid injection. At 12-month follow-up, differences in a validated score of shoulder function (Oxford Shoulder Score 0-48) among the ACR, manipulation, and physical therapy groups reached statistical significance favoring ACR, but the differences were unlikely to be clinically important (ACR 40.3 [95% CI 38.9-41.7]; manipulation under anesthesia 38.3 [95% CI 36.9-39.7]; structured physical therapy 37.2 [95% CI 35.3-39.2]). The minimal clinically important effect size was designated prior to the study as a four- to five-point difference in the Oxford Shoulder Score. ACR carried a significantly higher risk of adverse events (n = 8), which included chest infection, stroke, and deep vein thrombosis.

FOLLOW UP — A general treatment scheme, including follow up, is provided above. (See 'General approach to management' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Shoulder soft tissue injuries (including rotator cuff)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Frozen shoulder (The Basics)" and "Patient education: Rotator cuff injury (The Basics)")

Beyond the Basics topics (see "Patient education: Frozen shoulder (Beyond the Basics)" and "Patient education: Rotator cuff tendinitis and tear (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Definition, etiology, and prognosis – Frozen shoulder (adhesive capsulitis) describes a painful and stiff glenohumeral joint that has lost distensibility of the capsule and range of motion (particularly abduction and external rotation). The condition is either primary (idiopathic), with or without predisposing conditions such as diabetes mellitus, or develops following shoulder trauma, such as a rotator cuff tear, proximal humerus fracture, or shoulder surgery. The condition is self-limited in the great majority, but symptoms may persist for many months in some cases. (See 'Etiology and pathophysiology' above.)

Diagnosis – Frozen shoulder is diagnosed clinically based on the history and physical examination. Passive and active ranges of motion are substantially reduced (picture 1). A subacromial injection test can be useful to distinguish frozen shoulder from subacromial conditions. (See 'Clinical presentation' above and 'Diagnosis' above and 'Injection test' above.)

Diagnostic imaging – Imaging studies are generally unnecessary to diagnose frozen shoulder. Plain radiographs of the shoulder can be helpful to rule out other disorders such as glenohumeral osteoarthritis. MRI and ultrasound often reveal characteristic changes in the soft tissues consistent with frozen shoulder and can be used to assess the rotator cuff. (See 'Imaging' above.)

Management – There is no consensus on the best approach to treatment. Initially, we suggest resting the shoulder and performing only gentle shoulder mobility exercises, rather than aggressive physical therapy (Grade 2B). More demanding exercises are added as the patient's symptoms and mobility improve. For patients with moderate to severe symptoms, we suggest giving an intraarticular injection of glucocorticoid and anesthetic (eg, triamcinolone 20 to 40 mg and 1 percent lidocaine 5 mL) (Grade 2C). For severe pain, we may add a suprascapular nerve block. Suggested exercises and a basic management plan are provided in the text. (See 'Management' above and 'Physical therapy' above and 'Glucocorticoid injection' above and 'General approach to management' above.)

Surgical referral – Truly refractory cases of frozen shoulder can be referred for surgical evaluation. In most cases, surgical referral should be deferred as long as the patient is making progress with nonoperative management. (See 'Referral and surgery' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Tore A Prestgaard, MD, who contributed to earlier versions of this topic review.

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