1: Orthopedics 1996 Oct;19(10):849-53

Thawing the frozen shoulder: the "patient" patient.

Miller MD, Wirth MA, Rockwood CA Jr.

Department of Orthopedics, US Air Force Academy Hospital, Colorado, USA.

Many different modalities have been advocated for the treatment of frozen shoulder (adhesive capsulitis), some of which can be associated with complications and morbidity. We retrospectively reviewed 50 patients with adhesive capsulitis treated by the senior author over a 10-year period. Treatment consisted of closely monitored home therapy using moist heat and antiinflammatory medication, and a physician-directed rehabilitation program. Without exception, every patient regained a significant amount of motion and returned to activities of daily living without pain.

PMID: 8905857 [PubMed - indexed for MEDLINE]

2: Scand J Rheumatol 1998;27(6):425-30

Treatment of "frozen shoulder" with distension and glucorticoid compared with glucorticoid alone. A randomised controlled trial.

Gam AN, Schydlowsky P, Rossel I, Remvig L, Jensen EM.

Department of Rheumatology, Bispebjerg Hospital, Copenhagen, Denmark.

This study is a comparison of treatments of idiopathic "Frozen Shoulder" (adhesive capsulitis), distension combined with steroid is compared with steroid alone. Evaluation was based on pain scales, analgesic usage, and range of motion outcome scales. Out of one-hundred twenty patients (age, mean 51, range 21-70) that were referred under the diagnosis FS, twenty-six fulfilled the criteria for inclusion in the study, but four patients did not want to participate in the trial, giving a total of 22 patients (age, mean 53, range 40-65) in the study. Patients were randomised by the envelope method. Two patients dropped-out, one in each treatment group thus leaving the study with 20 patients for the final statistical analysis. Eight were treated with steroid alone and 12 with distension combined with steroid. Patients received one treatment per week for a six weeks period with a follow-up at 12 weeks. They were evaluated by pain VAS on function and at rest within the study period, the different ranges of motion (ROM) were measured at inclusion time and subsequent afterwards at 3, 6, and 12 weeks. The VAS outcomes showed no difference between the treatments (VAS-function p=0,1; VAS-rest p=0.1), while in the distension group ROM showed significant improvement in all directions except extension (external p=0.0007, flexion p=0.03, extension p=0,01). The analgesic usage was significantly lower in the group treated with distension at the end of the study (p=0.008). A blinded clinical assessment of ROM also showed significant improvement (p=0.002). It is concluded that distension with steroid can seem to help in management of "Frozen Shoulder". Other studies seems to support the conclusion.

3: Drug Ther Bull 2000 Nov;38(11):86-8

Need patients be stuck with frozen shoulder?

Frozen shoulder affects an estimated 2% of adults. The characteristic symptoms of pain, stiffness and limitation of movement may be sufficient to interfere with everyday activity (e.g. driving, dressing or sleeping) and may prevent some patients from working. Here, we review potential ways of minimising pain and disability.

4: Clin Orthop 1992 Sep;(282):105-9

Combination treatment for adhesive capsulitis of the shoulder.

Ekelund AL, Rydell N.

Department of Orthopaedic Surgery, St. Goran's Hospital, Stockholm, Sweden.

Twenty-two patients (23 shoulders) with arthrographically verified adhesive capsulitis of the glenohumeral joint were treated by a combination of distention-arthrography, local anesthetics and steroids intraarticularly, and manipulation. The mean duration of the disease at the time of treatment was 14 months, and all patients suffered from disabling pain and stiffness. A rapid improvement was seen after treatment and at four to six weeks: 91% (21/23) of the patients had no or slight pain and 83% (19/23) of the patients had normal, or almost normal, range of motion. The treatment was well tolerated and no complications were recorded. The combination treatment for adhesive capsulitis of the shoulder is safe, yields immediate results, and is cost effective.

5: Am Fam Physician 1999 Apr 1;59(7):1843-52

Adhesive capsulitis: a sticky issue.

Siegel LB, Cohen NJ, Gall EP.

Division of Rheumatology, Finch University of Health Sciences/Chicago Medical School, North Chicago, Illinois 60064, USA.

The shoulder is a very complex joint that is crucial to many activities of daily living. Decreased shoulder mobility is a serious clinical finding. A global decrease in shoulder range of motion is called adhesive capsulitis, referring to the actual adherence of the shoulder capsule to the humeral head. Adhesive capsulitis is a syndrome defined as idiopathic restriction of shoulder movement that is usually painful at onset. Secondary causes include alteration of the supporting structures of and around the shoulder, and autoimmune, endocrine or other systemic diseases. The three defined stages of this condition are the painful stage, the adhesive stage and the recovery stage. Although recovery is usually spontaneous, treatment with intra-articular corticosteroids and gentle but persistent physical therapy may provide a better outcome, resulting in little functional compromise.

6: Int J Tissue React 1998;20(4):125-30

Intraarticular injection of sodium hyaluronate plus steroid versus steroid in adhesive capsulitis of the shoulder.

Rovetta G, Monteforte P.

DISEM, Department of Rheumatology, Istituto Bruzzone ASL 3, University of Genova, Italy.

To determine the efficacy of a combined treatment--namely hyaluronan and corticosteroid injection plus physical exercises in the management of established idiopathic capsulitis of the shoulder--30 consecutive subjects with adhesive capsulitis were selected for the study. The diagnosis of adhesive capsulitis was established on the basis of a clinical history of spontaneous shoulder pain, shoulder examination showing passive limitation in conformity with capsular pattern, cervical examination excluding significant dysfunction of this area, plain radiographs excluding other significant shoulder diseases, or sonographic examination showing capsule shrinkage in affected joint. The patients were randomly allocated to receive intraarticular injections of sodium hyaluronate (20 mg) plus steroid (20 mg triamcinolone acetonide) and physiotherapy or intraarticular injections of steroid (20 mg triamcinolone acetonide) alone and physiotherapy. The intraarticular injections were performed at 15-day intervals in the first month and then monthly for 6 months. Physiotherapy was performed for 4-12 weeks. The results indicate an improvement of pain and joint motion after 6 months in all patients, especially in the patients treated with sodium hyaluronate. Intraarticular hyaluronan combined with triamcinolone acetonide and shoulder exercises may improve adhesive capsulitis. This drug possibly acts on shoulder tissue retraction by means of its influence on osmotic pressure and synovial fluid volume control.

7: Arch Phys Med Rehabil 1997 Aug;78(8):857-9

Frozen shoulder: correlation between the response to physical therapy and follow-up shoulder arthrography.

Mao CY, Jaw WC, Cheng HC.

Department of Physical Medicine and Rehabilitation, Taipei Municipal Yang Ming Hospital, Taiwan.

OBJECTIVE: To study the correlation between improvement of shoulder motion and shoulder joint space capacity determinated by arthrography. DESIGN: Case series. SETTING: General community hospital. PATIENTS: Twelve patients with clinically diagnosed frozen shoulder without rotator cuff tear. All subjects were divided as "primary" and "secondary" according to spontaneous onset or not, and "acute" or "chronic" depending on whether duration of disease was less than 2 months or longer. INTERVENTIONS: Outpatient rehabilitation programs, including physical modalities, exercise intervention, and regular weekly outpatient clinic follow-up. MAIN OUTCOME MEASURES: Shoulder range of motion (ROM) and joint space capacity in shoulder arthrography. RESULTS: In acute patients, the joint space capacity increased significantly after treatment (t = 2.82; p < .05). Increased joint space capacity was most significantly correlated with improvement in external rotation (r = .77, p < .05), followed by abduction (r = .43, p > .05), but was poorly correlated with flexion and internal rotation. In chronic patients, both primary and secondary groups, there was no obvious joint space capacity increase despite significant shoulder motion improvement. Follow-up arthrograms showed the reappearance and/or enlargement of the axillary recess and smoother capular margins in all the patients except one chronic case (disease duration for 1 year). These findings were more obvious in acute than in chronic patients. CONCLUSIONS: For frozen shoulder, generally described as "adhesive capsulitis," the adhesion was reversible in the acute stage. The increase of joint space capacity was significant and was correlated with improvement of external rotation. In chronic patients, ROM restoration occurred independent of change in joint space capacity, which increased slightly. The stretching of other contracted soft tissues around the shoulder, in addition to the adhesive capsule, may contribute to the recovery of chronic frozen shoulder.

8: Phys Ther 1986 Dec;66(12):1878-83

Frozen shoulder.

Wadsworth CT.

Widespread use of the label "frozen shoulder" as a diagnosis for any stiff and painful shoulder condition has led to its becoming a rather meaningless, catchall term. In addition to confounding both the lay public and health care professionals, this indiscriminate labeling may prevent a patient from receiving appropriate treatment. In this article, I define frozen shoulder and review its pathologic and etiologic factors, epidemiology, natural history, and diagnosis. I present this information in correlation with an examination process to assist physical therapists in identifying suspected cases of frozen shoulder. I also present the current options for treatment, including physical therapy management with physical agents and exercise.

9:  J Bone Joint Surg Am 1992 Jun;74(5):738-46

Frozen shoulder. A long-term follow-up.

Shaffer B, Tibone JE, Kerlan RK.

Kerlan-Jobe Orthopaedic Clinic, Inglewood, California 90301.

Sixty-two patients (sixty-eight shoulders) who had been treated non-operatively for idiopathic frozen shoulder were evaluated subjectively and objectively at two years and two months to eleven years and nine months of follow-up (average, seven years). Thirty-one (50 per cent) of these patients still had either mild pain or stiffness of the shoulder, or both. The range of motion averaged 161 degrees of forward flexion, 157 degrees of forward elevation, 149 degrees of abduction, 65 degrees of external rotation, and internal rotation to the level of the fifth thoracic spinous process. Thirty-seven (60 per cent) of the sixty-two patients still demonstrated some restriction of motion as compared with study-generated control values (calculated as the average motion, in each plane, for the thirty-seven unaffected shoulders of the patients who had unilateral disease). Ten patients had restriction of forward flexion; eight, of forward elevation; seventeen, of abduction; twenty-nine, of external rotation; and ten, of internal rotation. However, when the motion of each affected shoulder of thirty-seven patients who had unilateral involvement was compared with that of the unaffected contralateral shoulder, eleven (30 per cent) demonstrated some restriction. None of these patients had restriction of forward flexion; two had restriction of forward elevation; two, of abduction; seven, of external rotation; and seven, of internal rotation. The patients who had substantial restriction in three planes or more were thirteen times more likely to be men (p greater than 0.05). Marked restriction, when it was present, was most commonly in external rotation. Only seven patients (11 per cent) reported mild functional limitation.

10: Arch Orthop Trauma Surg 1995;114(2):87-91

Frozen shoulder--treatment and results.

Melzer C, Wallny T, Wirth CJ, Hoffmann S.

Orthopadische Klinik, Justus-Liebig-Universitat, Giessen, Germany.

Even today the aetiology of the frozen shoulder is still under discussion. At the Orthopaedic Department of the Medizinische Hochschule Hannover, 118 persons with a frozen shoulder were treated as in- or outpatients between 1980 and 1988. We investigated the results of two different specific therapy concepts. Most of the patients received a mixture of drug therapy and physical rehabilitation under the guidance of a physiotherapist. In a smaller group of patients, the frozen shoulder was mobilized under anaesthesia (mobilisation force). After an average follow-up time of 3.8 years from the start of treatment, 93% of the patients was examined by means of an individual subjective rating (score). In addition, a clinical examination was performed in 69% of the cases. According to the subjective personal rating (score) as well as the improvement in range of motion, moderate mobilisation led to better results than the mobilisation under anaesthesia.

11: Clin Orthop 2000 Mar;(372):95-109

Adhesive capsulitis. A treatment approach.

Hannafin JA, Chiaia TA.

Sports Medicine and Shoulder Service, NY, USA.

Adhesive capsulitis of the shoulder is a condition of unknown etiology that results in the development of restriction of active and passive glenohumeral motion. The authors will review what currently is known about the etiology of idiopathic adhesive capsulitis, will raise unanswered questions regarding etiology and treatment, and will define a stage-based evaluation and treatment program. Treatment options including benign neglect, home-based and supervised physical therapy, intraarticular corticosteroid injections, closed manipulations, and arthroscopic capsular release will be reviewed critically and the authors' approach to the treatment of patients with idiopathic adhesive capsulitis also will be presented. Additionally, areas of future research will be defined.

12: Arch Phys Med Rehabil 1991 Jan;72(1):20-2

Corticosteroid injections in adhesive capsulitis: investigation of their value and site.

Rizk TE, Pinals RS, Talaiver AS.

University of Tennessee College of Medicine, Memphis.

Forty-eight patients with frozen shoulder for less than six months were assigned at random to receive three shoulder injections into the subacromial bursa or glenohumeral joint at weekly intervals. The treatment groups were (1) intra-articular methylprednisolone and lidocaine, (2) intrabursal methylprednisolone and lidocaine, (3) intra-articular lidocaine, (4) intrabursal lidocaine. The same physical therapy program was carried out for all patients. Assessments of pain and range of motion were performed by a physical therapist who was uninformed about the nature of the injection therapy. There was no significant difference in outcome between intrabursal injection and intra-articular injection. Injection of steroid with lidocaine had no advantage over lidocaine alone in restoring shoulder motion, but partial, transient pain relief occurred in two thirds of the steroid-treated patients.

13: Orthop Rev 1993 Apr;22(4):425-33

Adhesive capsulitis of the shoulder.

Hulstyn MJ, Weiss AP.

Department of Orthopaedic Surgery, Brown University School of Medicine, Rhode Island Hospital, Providence.

Adhesive capsulitis of the shoulder is a relatively common problem that can cause significant functional morbidity in a wide variety of patient populations. Numerous treatment methods have been advocated and are reviewed and summarized in this article. Although several advances have been made in determining the etiology of this disorder, it remains poorly understood and without any definitive treatment algorithm.