1: J Shoulder Elbow Surg 2000 Jan-Feb;9(1):16-22

Frozen shoulder: a 12-month clinical outcome trial.

Watson L, Dalziel R, Story I

Sports Medicine Centres of Victoria, Melbourne Orthopaedic Group, Prahran, Australia.

A prospective study was undertaken of 73 patients with frozen shoulder syndrome who were treated with an arthroscopic capsulotomy. All of the patients were assessed for pain, function, and range of motion before surgery and were monitored through to 1-year follow up. Improvement in all parameters was achieved, with pain taking an average of 2.24 weeks to diminish and range of motion improving to within 10% of the other side at an average of 5.5 weeks after surgery. Patients were discharged with a full range of motion and without pain at an average of 8.9 weeks. There was, however, some mild reaggravation of most patients' pain within the postoperative period (mean 4.5 weeks). This pain usually settled with appropriate massage within a 2-week period. In 37% of cases, however, an injection of corticosteroid was required as part of the postoperative management. These cases were usually in that subgroup of patients who still had significant night pain and were in stage 2 or 3 of the disease process at the time of surgery. The postoperative results continued to the 12-month follow-up, with 11% of patients having a recurrence of pain or stiffness. This study has demonstrated that arthroscopic capsulotomy is an effective technique in the management of the frozen shoulder. It also has enabled the authors to document postoperative recovery times, which has given prospective patients realistic time frames of functional expectation in their postoperative recovery.

2: J Orthop Sci 1999;4(6):462-71

Management of the stiff shoulder.

Goldberg BA, Scarlat MM, Harryman DT 2nd

Department of Orthopaedics, Box 356500, University of Washington Medical Center, 1959 N. E. Pacific Street, Seattle, WA 98195, USA.

Shoulder stiffness occurs as a result of (1) contractures of the intraarticular capsule or muscle-tendon units or (2) adhesions within the extraarticular humeroscapular or scapulothoracic motion interface. These contractures or adhesions may occur independently or in combination. A thorough history and physical examination usually reveal the diagnosis (idiopathic frozen shoulder or posttraumatic stiff shoulder) and the anatomical locations of fibrosis that is causing stiffness, and identifies other treatable conditions associated with shoulder stiffness (such as diabetes). A gentle home program of passive stretching is effective in most patients. When the home program is not effective, a manipulation or surgical release may be indicated. If manipulation is not effective, capsular contractures are best released arthroscopically as this allows circumferential release without damaging the rotator cuff and thus allows rehabilitation without the need to protect the rotator cuff. The humeroscapular motion interface adhesions can be released either open or arthroscopically, but we believe that an open release combined with an arthroscopic capsular release is quicker and does not interfere with rehabilitation. When necessary, operative management coupled with an aggressive rehabilitation program can provide significant relief of pain and restoration of shoulder motion. Approximately 90% of patients can expect a good result with this treatment algorithm.

3: Arch Orthop Trauma Surg 2000;120(1-2):84-7

Frozen shoulder: a sympathetic dystrophy?

Muller LP, Muller LA, Happ J, Kerschbaumer F

Johannes Gutenberg-Universitat Mainz, Klinik und Poliklinik fur Unfallchirurgie, Germany. mueller@ach.klinik.uni-mainz.de

Diagnostic and clinical features of the frozen shoulder syndrome and the Sudeck syndrome are similar in many aspects. Radioisotope bone scan shows an increased uptake in affected areas in both diseases, while native radiographs show a progressive demineralisation. Measurement of bone mineral density (BMD) by quantitative digital radiography objectified these local decalcification processes in an early stage of the frozen shoulder syndrome; 10 of 12 patients with primary frozen shoulder had BMD decreases greater 21% in the humeral head of the affected shoulder compared to the non-affected side. In the immobilised control group with degenerative changes of the rotator cuff, calcifying tendinitis and shoulder instability (n = 12) and in the group of healthy probands (n = 20), the difference between the affected and non-affected side (left and right humerus of the healthy probands) was only more than 21% in one case each. There are several references in the literature that assume frozen shoulder to be an algoneurodystrophic process; our observations support this hypothesis, possibly leading to earlier diagnoses and extended therapeutic management.

4: Arch Orthop Trauma Surg 1999;119(7-8):363-7

Bone mineral density of the shoulder joint in frozen shoulder.

Okamura K, Ozaki J

Department of Orthopaedic Surgery, Nara Prefectural Hospital, Japan.

The purpose of this study was to evaluate the osteopenia in several parts of the shoulder joint in a series of individuals suffering from frozen shoulder and to elucidate the pathogenesis. The bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DEXA). In 30 cases of frozen shoulder, 16 men and 14 women, BMD of the head of the humerus, greater tubercle of the humerus, surgical neck of the humerus, and neck of the scapula was evaluated. The average age of the male patients was 58.4 years and of the women, 59.5 years. At the neck of the scapula, there were no significant differences in any of the cases. However, there was a marked decrease in BMD at the proximal end of the humerus on the affected side of women. In contrast, men showed no significant difference between the affected and unaffected shoulders, suggesting that the degree of osteopenia remains low compared with women. Although frozen shoulder is a disease which may occur in both men and women, the loss of bone was conspicuous only in women. This may be due to the involvement of female hormones in alterations of bone in frozen shoulder, as in cases of osteoporosis, in addition to the originally low bone density in women. The degree of osteopenia of the proximal humerus with frozen shoulder was not correlated with the duration of the disease, range of motion of the shoulder joint, or patient's age.

5: J Am Board Fam Pract 1999 Jul-Aug;12(4):270-7

Simple home program for frozen shoulder to improve patients' assessment of shoulder function and health status.

O'Kane JW, Jackins S, Sidles JA, Smith KL, Matsen FA 3rd

Department of Orthopaedics, University of Washington, Seattle, USA.

BACKGROUND: The purpose of this investigation was to test the hypothesis that a simple home program can improve the self-assessed shoulder function and health status of a group of patients with frozen shoulders. METHODS: A case series using a one-group pretest, posttest design analyzing 41 patients from a single orthopedic practice who had a frozen shoulder were included in this study. The patients completed the Simple Shoulder Test (SST) and the Medical Outcomes Study Short-Form Health Survey (SF-36) questionnaire at the time of initial consultation, had treatment consisting of education regarding frozen shoulder and home stretching instructions, and were asked to complete the same questionnaires mailed every 6 months. Initial results were compared with previously published control values to establish level of impairment, and follow-up results were compared with the initial results to determine the extent of improvement. RESULTS: Patients initially had serious deficits in the 12 shoulder functions inventoried by the SST and were also compromised in their general health status as reflected by the SF-36 scores. At follow-up, 4 of 10 SST functions were improved (P < 0.001). The SF-36 health status scores of physical function, comfort, and physical role function were also improved (P < 0.001). CONCLUSION: These data suggest that this home program for frozen shoulder can lead to improved self-assessed shoulder function and health status in patients similar to those in the study population.

6: Md Med J 1999 Jan-Feb;48(1):7-11

Long-term functional results after manipulation of the frozen shoulder.

Reichmister JP, Friedman SL

Department of Orthopaedic Surgery, Sinai Hospital, USA.

The use of shoulder manipulation in the treatment of frozen shoulder syndrome remains controversial. Opponents cite the risk of dislocation, fracture, nerve palsy, and rotator cuff tearing as limiting the usefulness of manipulation. A retrospective study of 38 shoulder manipulations in 32 patients was performed. These patients were followed for an average time of 58 months. The patients were examined in follow up for combined shoulder range of motion, external and internal rotation strength, and status of the long head of the biceps. Manipulation was performed in all patients by the senior author and supervised physical therapy was begun within 24 hours of the manipulation. The average recovery time was 13 weeks. In this series, 97% of patients had relief of pain and recovery of near complete range of motion, although 8% required a second manipulation to obtain a successful result. Mild weakness to manual muscle testing was present in 5.3% of patients in external rotation and 10.5% of patients in internal rotation. There was no deterioration of shoulder function with time. In fact, most patients improved with passage of time, even more. There was no evidence of biceps tendon rupture or rotator cuff insufficiency at the time of follow up in any of the patients. No fractures, dislocations or nerve palsies were observed, although one patient who had no premanipulation arthrogram was found to have a rotator cuff tear a few months after failed manipulation. Manipulation of the shoulder can therefore be offered to reduce the pain and period of disability in patients who fail conservative treatment of frozen shoulder syndrome.

7: Arthroscopy 1999 Jan-Feb;15(1):2-11

An arthroscopic technique for treating patients with frozen shoulder.

Pearsall AW 4th, Osbahr DC, Speer KP

Department of Orthopaedic Surgery, University of South Alabama, Mobile, USA.

Forty-three patients with a diagnosis of primary or secondary frozen shoulder who had symptoms for an average of 12 months and failed conservative treatment of at least 12 weeks of physical therapy, were treated with an arthrosopic capsular release. On completion of standard shoulder arthroscopy, intra-articular cautery was used to completely divide the anterior-inferior capsule, the intra-articular portion of the subscapularis tendon, and the middle glenohumeral, the superior glenohumeral, and the coracohumeral ligaments. The subacromial space was inspected in all patients. Eighteen patients had extensive subacromial fibrosis that required debridement. Subacromial decompression was reserved for patients with evidence of an acromial spur seen at the time of arthroscopy. Postoperatively, all patients showed substantial gains in shoulder range of motion, as well as diminished shoulder pain. Thirty-five patients completed a telephone survey at an average of 22 months after surgery. The average modified shoulder score was 19 (scale, 13 to 65), with 83% of patients indicating that their shoulder was normal or caused only mild symptoms. In conclusion, the authors believe that arthroscopic capsular release is an effective and safe alternative to manipulation in patients with a recalcitrant frozen shoulder.

8: Acta Orthop Belg 1998 Dec;64(4):434-40

Frozen shoulder--an algoneurodystrophic process?

Muller LP, Rittmeister M, John J, Happ J, Kerschbaumer F

Johannes Gutenberg-Universitat Mainz, Klinik und Poliklinik fur Unfallchirurgie.

The frozen shoulder syndrome and the Sudeck syndrome are clinically in many aspects similar. Radioisotope bone scan shows an increased uptake in the affected areas in both diseases, while standard radiographs show a progressive demineralization. With measurement of bone-mineral density by quantitative digital radiography these local decalcification processes were diagnosed in an early stage of the frozen shoulder syndrome: of 12 patients with primary frozen shoulder 10 had a bone-mineral density decrease of more than 21% in the humeral head of the affected shoulder compared to the unaffected side. In the control groups (n = 32) the difference between affected and unaffected side (left and right humerus of the healthy probands) was in only one case each above 21%. There are several indications in the literature assuming the frozen shoulder to be an algoneurodystrophic process. Our observation supports this hypothesis, and may possibly lead to earlier diagnosis and improved therapeutic management.

9: 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.

10: J Bone Joint Surg Br 1998 Sep;80(5):907-8

Dupuytren's disease and frozen shoulder induced by treatment with a matrix metalloproteinase inhibitor.

Hutchinson JW, Tierney GM, Parsons SL, Davis TR

Queen's Medical Centre, Nottingham, England, UK.

In a series of 12 patients with inoperable gastric carcinoma who had treatment with a synthetic matrix metalloproteinase inhibitor (Marimastat) for more than one month, six developed a frozen shoulder or a condition resembling Dupuytren's disease. This suggests that the matrix metalloproteinases, a family of naturally occurring proteinases, may be involved in the pathogenesis of these two conditions. Our observation opens avenues for further research which could lead to local or systemic therapeutic interventions for frozen shoulder and Dupuytren's disease.

11: Clin Rehabil 1998 Jun;12(3):211-5

Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens.

de Jong BA, Dahmen R, Hogeweg JA, Marti RK

Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, The Netherlands.

BACKGROUND AND PURPOSE: Although corticosteroid injections have been reported to be effective in capsulitis of the shoulder, the optimal dose has not been established. The purpose of this study was to compare relief of symptoms following a lower dose with that following a higher dose of triamcinolone acetonide given intra-articularly. SUBJECTS: Thirty-two patients were given low dose suspension; 25 patients were given high dose suspension. METHOD: Randomized, double-blind clinical trial. Each patient was given a course of three injections. Pain, sleep disturbance, functional impairment and passive range of motion (ROM) were assessed at intake and at one, three and six weeks after the initial injection. Data were analysed by independent sample t-tests and nonparametric Mann-Whitney U-tests. RESULTS: The group which received the 40 mg dose showed significantly greater improvement than the group receiving the 10 mg dose. CONCLUSIONS: The study shows that in the treatment of frozen shoulder greater symptom relief is obtained with a dose of 40 mg triamcinolone acetonide intra-articularly than with a dose of 10 mg. The effect on pain and sleep disturbance was more marked than on ROM. Intra-articular injections with triamcinolone acetonide appear to be an effective method to obtain symptom relief for patients with painful capsulitis of the shoulder.

12: J Shoulder Elbow Surg 1998 May-Jun;7(3):218-22

Frozen shoulder: arthroscopy and manipulation under general anesthesia and early passive motion.

Andersen NH, Sojbjerg JO, Johannsen HV, Sneppen O

Department of Orthopaedics, University Hospital of Aarhus, Denmark.

During a 15-month period, 24 patients with arthroscopically verified frozen shoulders were treated with manipulation while under general anesthesia and early passive motion. The minimum follow-up was 12 months, and the average duration from onset of the disease until treatment was 8 months. All patients had moderate to severe pain, and the average range of motion was less than 40% of the opposite shoulder. During the follow-up period, 75% of the patients obtained normal or almost full range of motion, and 79% had slight pain or no pain at all. Eighteen (75%) patients returned to work 9 weeks (mean) after treatment. There was no relationship between the end result and the initial pathologic condition. We believe that manipulation combined with arthroscopy is an effective way of shortening the course of an apparently self-limiting disease and should be considered when conservative treatment has failed.

13: Bone 1998 Jun;22(6):691-4

Adhesive capsulitis of the shoulder (frozen shoulder) produces bone loss in the affected humerus, but long-term bony recovery is good.

Leppala J, Kannus P, Sievanen H, Jarvinen M, Vuori I

Accident and Trauma Research Center, UKK Institute for Health Promotion Research, Tampere, Finland.

The objective of the study was to assess the short- and long-term effects of adhesive capsulitis (frozen shoulder) on the bone mineral density (BMD) of the affected extremity. BMD and clinical status of 22 patients (group A) with active-phase unilateral adhesive capsulitis and 31 patients (group B) with a previous adhesive capsulitis (average 9 years before the examination) were determined. BMD was measured from the proximal humerus, humeral shaft, radial shaft, ulnar shaft, and distal forearm of both upper extremities using dual-energy X-ray absorptiometry (DXA). In group A, the mean BMD of the affected extremity, as compared with that of the unaffected side, was significantly lower in the proximal humerus (-5.6%; p = 0.001) and humeral shaft (-3.0%; p = 0.008). The radial shaft, ulnar shaft, and distal forearm showed no significant side-to-side differences. In contrast, in group B, the affected-to-unaffected side BMD differences were small and statistically insignificant. Compared with the 31 patients in group B, the relative side-to-side BMD difference of the 22 patients with active-phase disease (group A) was significantly lower in the proximal humerus (-5.6% vs. -1.5%, p = 0.009). In the other sites, groups A and B showed no significant differences. In conclusion, this study indicates that adhesive capsulitis of the shoulder results in significant bone loss in the humerus of the affected extremity, but in the long term, capsulitis-induced bone loss shows good recovery.

14: Med Sci Sports Exerc 1998 Apr;30(4 Suppl):S33-9

Frozen shoulder syndrome: diagnostic and treatment strategies in the primary care setting.

Pearsall AW, Speer KP

Department of Orthopaedic Surgery, University of South Alabama, Mobile 36617, USA.

The term "frozen shoulder" has been used to describe an array of clinical conditions. The authors consider a patient as meeting the criteria of primary or secondary frozen shoulder syndrome if he/she has a clinical history of worsening painful shoulder motion loss of at least 1 month duration and a physical examination documenting painful restricted shoulder motion. In the evaluation of the patient with suspected FSS, initial screening shoulder radiographs are required to exclude other conditions. The physical examination of the frozen shoulder patient should include observation, cervical examination, assessment of range of motion, and the use of provocative testing. The treatment of the patient with FSS should include preventative education, various medications including NSAIDS and oral corticosteroids, physical therapy, and finally, for the patient with refractory symptoms, surgical intervention. For those patients necessitating surgical intervention, the authors recommend a selective arthroscopic capsular release.

15: Rev Rhum Engl Ed 1998 Jan;65(1):72-4

Frozen shoulder: a new delayed complication of protease inhibitor therapy?

Zabraniecki L, Doub A, Mularczyk M, Andrieu V, Marc V, Ginesty E, Dromer C, Massip P, Fournie B

Rheumatology Department, Purpan Teaching Hospital, Toulouse, France.

We report three cases of frozen shoulder (including one with bilateral involvement) in human immunodeficiency virus (HIV)-positive patients under triple antiretroviral therapy. In each case, the diagnosis was confirmed by arthrography, and the classic causes of frozen shoulder were ruled out. We suggest that protease inhibitor therapy may have contributed to the development of frozen shoulder in these patients. Long-term follow-up of the increasing numbers of patients under triple antiretroviral therapy will confirm or refute this hypothesis.

16: J Shoulder Elbow Surg 1997 Nov-Dec;6(6):534-43

Abnormal synovium in the frozen shoulder: a preliminary report with dynamic magnetic resonance imaging.

Tamai K, Yamato M

Department of Orthopaedic Surgery, Dokkyo University School of Medicine, Tochigi, Japan.

We studied 16 patients (18 shoulders) with frozen shoulders, 8 patients with subacromial impingement syndrome, and 3 healthy volunteers with dynamic magnetic resonance imaging enhanced with gadolinium diethylenetriaminepentaacetic acid. After intravenous contrast was administered, gradient-recalled echo images were obtained in the oblique coronal plane every 11 to 13 seconds for a total period of 4 to 5 minutes. The signal intensity was measured at the periphery of the glenohumeral joint and in the subacromial bursa. The coefficient of enhancement (percent signal increase per second) in the frozen shoulders was 1.33 +/- 0.43 (mean +/- SD) for the glenohumeral joint and 0.89 +/- 0.47 for the subacromial bursa. These values were far greater than those in subacromial impingement syndrome or in the control group, indicating increased blood flow to the synovium in the frozen shoulders. No previous reports have shown a clinical measure related to the pathophysiology of this disease.

17: 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.

18: Z Orthop Ihre Grenzgeb 1997 May-Jun;135(3):222-7

["Primary" shoulder stiffness: illness duration and therapeutic comparison].

Wallny T, Melzer C, Wagner U, Wirth CJ, Schmitt O

Orthopadische Universitatsklinik Bonn.

AIMS: Etiology, natural history and therapy of the frozen shoulder still remains obscure. Therefore observation of natural history is of interest. METHOD: In a retrospective study 140 patients with different therapies were followed-up. RESULTS: 28 (20%) patients were not considered as healed because of persisting complaints during the whole follow-up period with an average duration of 49 months. Mobilisation under anaesthesia (27 patients) showed an less improval in range of motion with a shortening of complaint period. CONCLUSION: The existence of a subgroup of patients with no response on regular therapy is assumed.

20: J Orthop Sports Phys Ther 1996 Mar;23(3):216-22 Related Articles, Books, LinkOut

Anterior-inferior capsular length insufficiency in the painful shoulder.

Hjelm R, Draper C, Spencer S

Rosedale Family Physical Therapy, Roseville, MN, USA.

Our clinic's initial attempts to document shoulder capsular laxity made us increasingly aware of the presence of subtle restricted passive shoulder movement in patients with a variety of shoulder diagnoses. The purpose of this study is to describe the evaluation, physical therapy treatment, pathomechanics, and implications of a continuum of anterior-inferior capsular length insufficiency and shoulder pain. One hundred fifty-six patients with the diagnoses of shoulder pain, impingement, rotator cuff tendinitis, and frozen shoulder were found to have capsular length insufficiency and were treated by mobilization techniques deemed as manual decompression. Eighty-three percent displayed good to excellent outcomes for decreasing pain, increasing range of motion, and meeting functional goals. Recent literature has supported the concept that capsular ligaments not only provide restraint, but are specifically oriented to guide and center the humeral head on the glenoid during shoulder movements. These patients presented with abnormal glenohumeral mechanics due to anterior capsular ligament length insufficiency. Glenohumeral ligament length insufficiency can be the primary cause of shoulder pain, ranging from frozen shoulder to impingement-like symptoms. Proper capsular ligament length can be restored with manual techniques. All patients with shoulder pain should have capsular ligament length assessment to ensure proper glenohumeral mechanics.