FROZEN SHOULDER (ADHESIVE CAPSULITIS): HOW TO RECOGNIZE IT AND TREAT IT
Adhesive capsulitis: what to do? Tips, treatments, and FAQs for treating frozen shoulder effectively
Gabriele February
18 min.Dec 18, 2024
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Frozen Shoulder (Adhesive Capsulitis): How to Recognize and Treat It
What is Frozen Shoulder (or adhesive capsulitis)?
Adhesive capsulitis, better known as frozen shoulder, is a painful and limiting condition characterized by stiffness and decreased shoulder movement. This condition typically affects people between the ages of 40 and 60 and can be very debilitating.
Causes and risk factors of adhesive capsulitis
The exact cause of frozen shoulder is not yet fully understood, but it is thought to be the result of inflammation, scarring, or adhesions within the shoulder joint capsule.
Capsulitis is characterized by thickening and stiffening of the shoulder capsule, resulting in stiffness and limited movement.
Causes and risk factors are important elements in understanding the nature and origin of a phenomenon or condition. In the context of health, these variables play a key role in the onset and development of diseases, disorders, and pathologies.
The causes of a health condition can be diverse. They may arise from genetic, environmental, behavioral factors, or a combination of these factors. For example, some diseases can be caused by genetic mutations inherited from parents, while others may be the result of negative environmental influences, such as exposure to toxins or pollutants. Similarly, an unhealthy lifestyle, characterized by poor eating habits, a sedentary lifestyle, or excessive use of harmful substances, can increase the risk of developing certain diseases.
Risk factors, on the other hand, are conditions or behaviors that increase the likelihood of developing a disease or condition. They can be categorized based on their nature, such as modifiable and non-modifiable risk factors. Modifiable risk factors include variables such as smoking, alcoholism, obesity, lack of physical activity, and excessive salt and fat consumption, while non-modifiable risk factors include age, gender, family history, and genetic predisposition.
Recognizing and understanding the causes and risk factors associated with a given condition is essential to prevent the onset of diseases and disorders.
Several risk factors for adhesive capsulitis have been identified. These include diabetes, previous trauma, prolonged immobilization of the glenohumeral joint, and certain medical conditions such as hypothyroidism, hyperthyroidism, Parkinson's disease, and heart disease. Furthermore, demographic studies have shown that the condition most commonly affects individuals between the ages of 40 and 60, with a higher prevalence in women. Furthermore, genetic predisposition and psychiatric conditions, such as stress reactions and adjustment disorders, have been associated with adhesive capsulitis. Understanding these causes and risk factors is crucial for early identification and management of this debilitating shoulder condition.
Thyroid dysfunction and its correlation with frozen shoulder
Thyroid dysfunction is a condition that affects the thyroid gland, which is responsible for regulating the body's metabolism. This condition can lead to a variety of symptoms, including fatigue, weight gain, excessive sensitivity to cold, and other health problems.
Recent studies have also indicated a possible correlation between thyroid dysfunction and frozen shoulder.
Some researchers have hypothesized that thyroid dysfunction may cause systemic inflammation in the body, including the connective tissues in joints like the shoulder. Others argue that metabolic changes associated with thyroid dysfunction may affect joint health and contribute to the onset of frozen shoulder.
While the exact relationship between thyroid dysfunction and frozen shoulder is still a matter of debate and study, it is important for patients with thyroid dysfunction to be aware of this possible link and to discuss any joint symptoms with their doctor.
Connective tissue involvement
Connective tissue involvement is crucial in many pathological conditions and diseases. Connective tissue is composed primarily of specialized cells called fibroblasts and an extracellular matrix rich in proteins such as collagen, elastin, and glycosaminoglycans. This tissue plays a fundamental role in supporting and connecting other tissues and organs in the body.
In many diseases, connective tissue can be affected in various ways, leading to a variety of problems and complications. In cystic fibrosis, a genetic disease, thick mucus builds up in the lungs, causing breathing problems and recurrent infections. Connective tissue involvement is crucial in autoimmune diseases such as systemic lupus erythematosus and scleroderma, in which the immune system damages blood vessels, joints, and organs.
"Frozen shoulder" involves inflammation and fibrosis within the joint capsule, resulting in thickening and stiffening of the shoulder capsule. Histologically, the initial phase is characterized by inflammatory cell infiltration of the synovium, followed by synovial proliferation and the development of dense collagenous tissue within the capsule. These connective tissue changes contribute to the stiffness and limited range of motion seen in adhesive capsulitis. The progression of the disease through various stages, including the inflammatory and fibrotic phases, highlights the complex nature of the connective tissue changes that occur in adhesive capsulitis.
Identifying the Symptoms
Signs you shouldn't ignore
The stages of adhesive capsulitis
Frozen shoulder goes through several stages.
The initial phase is the pre-frostbite phase, in which mild pain occurs and the shoulder begins to progressively lose its range of motion. This phase can last from a few weeks to several months.
The next stage is the freezing stage, in which the pain and stiffness of the shoulder become more intense and movement is significantly limited. This stage can last from 4 to 12 months.
Finally, there's the thawing phase, in which the pain begins to subside and shoulder movement begins to improve. This phase can last from six months to several years.
Treatment for frozen shoulder varies depending on the stage of the condition.
- In the initial, pre-freezing phase, the focus is on pain management and increasing shoulder mobility through stretching exercises and fisioterapia.In Generally speaking, this is the crucial moment because, at this stage, the disease is often mistaken for tendinitis or simple inflammation. However, in the opinion of the shoulder surgeon who can recognize it at this stage, intervention significantly reduces the healing time of the three phases. If the inflammation of the capsule is prevented or reduced at this stage, all the other phases will be less intense, shorter, or both!
- During the frostbite phase, anti-inflammatory medications or direct cortisone injections into the shoulder may be prescribed to reduce inflammation and pain. It's important at this stage, since the capsule is still contracting, not to gain movement, but to try to minimize its loss. Physical therapy during these phases can be very painful and should be supported with appropriate pharmacological therapy.
- During the thawing phase, physical therapy and shoulder strengthening exercises become particularly important to fully restore movement. This is usually the most difficult phase for the patient because it takes a long time, and the results from week to week are difficult to perceive, even if they are present.
At every stage, it's important to keep the shoulder moving to prevent permanent loss of mobility. In some cases, surgery may be necessary to treat frozen shoulder, but this is reserved for the most severe cases that don't respond to other treatments.
Insidious onset similar to tendinitis in the early stages
It's especially important to recognize this condition in its early stages, because initially, frozen shoulder displays many signs that can be confused with rotator cuff tendinitis, a partial tear of the supraspinatus tendon, or a simple subacromial impingement, but it doesn't yet show signs of decreased range of motion. It's at this stage that a careful eye can intervene with targeted drug therapy to reduce the inflammation and even prevent the onset of the other two stages. However, identifying adhesive capsulitis in the early stages, or rather, at the very beginning of the first stage, is extremely difficult, even for shoulder surgery specialists. The biggest problem is that patients often underestimate the problem and proceed with inadequate self-treatment or simply consult a physical therapist, believing it's simply inflammation that will resolve with some rest and physical therapy. Only when the symptoms don't improve does the patient consult a shoulder surgeon, but unfortunately, by then the condition has already reached an advanced stage.
Diagnostic Pathways for Adhesive Capsulitis
Clinical examination and necessary investigations
Adhesive capsulitis presents with a gradual onset of shoulder pain and significant limitation of shoulder movement.
The clinical examination for adhesive capsulitis involves identifying characteristic features, such as reduced active and passive range of motion, particularly in forward flexion, abduction, and external and internal rotation. Palpation of the affected shoulder reveals diffuse tenderness around the shoulder joint (though this may also be absent at rest), while shoulder movement (both passive and active) causes pain and marked limitation (especially in external rotation), similar to a rotator cuff tear. Furthermore, in more severe cases, loss of the natural swing of the arm during walking and muscular dystrophy may be observed.
Although laboratory tests are not indicated for the diagnosis of adhesive capsulitis, targeted laboratory tests may be necessary to investigate and exclude other potential causes if an underlying disease or systemic condition is suspected to be contributing to the symptoms.
Imaging studies are not indicated for the diagnosis of adhesive capsulitis. The diagnosis is based primarily on clinical evaluation and patient history. However, if an alternative diagnosis, such as a fracture or other structural abnormality, is suspected, imaging studies, such as a shoulder X-ray or non-contrast magnetic resonance imaging (MRI), may be helpful.
When to see a specialist doctor
Given the extreme difficulty in diagnosing this disease, especially in its initial stages, it is advisable to consult a shoulder surgery specialist when shoulder pain persists for more than 7-10 days despite basic anti-inflammatory therapy prescribed by your family doctor.
At this point, the specialist will make the diagnosis and, if it is not capsulitis, proceed with a non-invasive treatment of physiotherapy or injections or with specific tests.
Of course, a specialist is also necessary in phases two and three, when the diagnosis can no longer be defined as timely but is still useful for setting the correct treatment.
Treatment Options for Recovery
Conservative treatments and pain management
Conservative treatment options for adhesive capsulitis aim to relieve symptoms and improve range of motion without surgery. These approaches typically include a combination of nonsteroidal anti-inflammatory drugs (NSAIDs) for initial pain control, supervised physical therapy, and intra-articular corticosteroid injections (note: intra-articular injections are different from subacromial injections, which are generally also performed by a shoulder surgery specialist).
Physical therapy may involve gentle range-of-motion exercises, stretching, and graded resistance training to reduce pain and increase function. However, it is crucial to avoid vigorous rehabilitation, which could exacerbate the condition, especially in phases one and two.
Intra-articular corticosteroid injections (not subacromial bursal injections, which miss the inflamed capsule!) have been shown to provide symptomatic relief and improve shoulder mobility. The goal of conservative treatment is to manage symptoms and facilitate gradual improvement in shoulder mobility, as adhesive capsulitis is often a self-limited condition with high rates of spontaneous recovery within 18–30 months.
Consistency over quantity is the key to non-surgical treatment
Consistency in non-surgical treatment is often more important than the amount of therapy applied. This principle is based on the idea that small, but regular, actions can lead to significant improvements over time. For example, in physical rehabilitation, light daily exercises help tissue healing better than intense, but sporadic sessions. The key is to faithfully adhere to the treatment plan, without becoming discouraged if results aren't seen immediately, allowing the body to adapt and respond positively over time.
Plexus mobilization under anesthesia for frozen shoulder (adhesive capsulitis)
Brachial plexus block mobilization for frozen shoulder has been proposed as an alternative to surgery, offering a shorter recovery time and avoiding the need for hospitalization. This approach provides a standardized method of brachial plexus block manipulation for patients with stage III adhesive capsulitis.
Studies have reported a high rate of satisfaction and recovery of range of motion after 4 months, indicating the potential effectiveness of this technique in providing temporary symptom relief. However, surgical management should only be considered if patients persist with symptoms despite long-term conservative therapy, as brachial plexus block mobilization offers a noninvasive option with promising results.
Surgical interventions: when are they necessary?
Arthroscopic treatment of frozen shoulder has been recognized as an effective intervention for patients who do not respond to conservative management.
This surgical approach involves arthroscopic capsular release, which aims to resolve the pathological process of synovial inflammation followed by capsular fibrosis. The procedure allows the tense and thickened joint capsule to be released and cut at specific points, thus improving range of motion and reducing pain.
Studies have shown that arthroscopic capsular release can lead to significant improvements in shoulder range of motion and function, particularly in patients with intractable pain and severe range of motion limitation.
Although conservative management is often the first-line approach, arthroscopic treatment becomes a viable option for patients who experience no symptomatic improvement and continued functional disability after a prolonged period of conservative treatment.
Rehabilitation as the Key to Success
Importance of personalized exercise
Physiotherapy plays a crucial role in the management of frozen shoulder, offering various benefits during the different stages of the condition.
- During the frostbite phase, shoulder mobilization exercises, applications of heat or ice packs, and pain-relieving techniques can help relieve discomfort and maintain some degree of mobility.
- Once the patient enters the thawing phase, physical therapy becomes essential to regain full range of motion and strength. Strengthening, mobility, and stretching exercises are gradually introduced to rebuild shoulder function and prevent further stiffness.
Furthermore, supervised physiotherapy has been shown to improve patient compliance and outcomes, particularly in the context of adhesive capsulitis, highlighting the importance of professional guidance and support in the rehabilitation process.
Prevention and Helpful Tips
Daily habits for a healthy shoulder
Maintaining healthy shoulder habits is essential to prevent strain and injury. Simple daily practices can contribute to shoulder health, such as paying attention to posture when sitting and sleeping, avoiding carrying heavy loads with outstretched arms, and taking regular breaks from repetitive activities.
Additionally, exercises to strengthen and lengthen the muscles and tendons of the shoulder joint can help reduce the risk of injury and improve shoulder function. These exercises may include stretching the back of the shoulder, performing hand-on-back stretches, and performing wall stretches. By incorporating these habits and exercises into your daily routine, you can promote shoulder health and reduce the likelihood of shoulder-related problems.
Nutrition and lifestyle tips that can make a difference
The use of supplements and medications in the management of frozen shoulder is a topic of ongoing clinical and research interest. While nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are commonly prescribed to relieve the pain and inflammation associated with frozen shoulder, their effectiveness in promoting long-term recovery remains a matter of debate.
Additionally, the potential role of supplements such as vitamin C in preventing or mitigating the development of frozen shoulder is being explored. Some studies have suggested that vitamin C may have prophylactic potential in shoulder contracture, although further research is needed to establish its definitive role in the prevention or treatment of frozen shoulder. As our understanding of the pathophysiology of frozen shoulder continues to evolve, the use of supplements and medications in its management will likely be refined based on emerging evidence.
Expectations and Healing Times
The typical course of adhesive capsulitis
Frozen shoulder goes through three phases with different timeframes:
- The pre-freezing phase can last from a few weeks to several months.
- The freezing phase can last from 4 to 12 months.
- The thawing phase can last from 6 months to several years.
When to expect a full recovery
Complete recovery from adhesive capsulitis can take six months to three years, with the thawing phase marking the period of gradual improvement and restoration of shoulder function.
Recovery time depends on the degree of mobility lost in stage 3 of capsulitis. For example, if 100° of anterior elevation is missing, with monthly recovery of 5-15°, it will take about 10 months of therapy to regain the remaining degrees. However, there are methods to speed up the process.
The times described refer to spontaneous recovery or recovery with the help of physical therapy. The therapies mentioned above can speed recovery, but there is no guarantee that injections or specific therapies will speed up the recovery process in phase 3. It is essential to begin the appropriate therapy in phases 1 and 2 to reduce the overall recovery time.
Insights and Resources
Scientific studies and latest research on adhesive capsulitis
By consulting the most bibliography this article and even more the news section you can further explore the topic between the three most debated shoulder surgeons.
FAQ - Frequently Asked Questions
What is the difference between adhesive capsulitis and tendonitis?
Adhesive capsulitis causes shoulder pain and stiffness, significantly limiting movement. This condition can develop when the capsule surrounding the shoulder joint becomes inflamed and narrowed. For example, it can occur after a period of shoulder immobilization following surgery. Conversely, tendinitis is the inflammation of a tendon, the structure that connects muscle to bone. A typical case of tendinitis is "supraspinatus tendinitis," which affects the shoulder tendons, causing pain especially during arm movement. Both conditions can result from overload or overuse of the joint.
Can adhesive capsulitis of the shoulder be prevented?
Short answer: no. While its exact cause remains incompletely understood, factors such as diabetes, thyroid problems, prolonged immobilization, or previous injuries are believed to increase the risk. Properly managing these conditions can theoretically reduce the risk of developing adhesive capsulitis. Preventing adhesive capsulitis involves keeping the shoulder joint mobile through regular stretching and mobility exercises, especially after an injury or during periods of forced inactivity. Promptly addressing conditions that increase the risk, such as poor glycemic control in diabetes, can also reduce the likelihood of developing it.
How long does it take to recover from frozen shoulder?
Full recovery from shoulder injury may take anywhere from six months to three years, with the thawing phase being the period during which gradual improvement and restoration of shoulder function occurs.
How effective are injections in treating adhesive capsulitis?
Intra-articular (not subacromial!) corticosteroid injections, administered alone or following shoulder capsule relaxation, have produced clinically significant improvements in the short term. Similarly, corticosteroid injections in the rotator cuff have shown promising results in terms of pain relief. However, the short-term benefits of steroids dissipated over time. Multisite corticosteroid injections demonstrated a clinical advantage over placebo for composite assessments of short- and medium-term outcomes.
For further information please see the section dedicated to the rotator cuff in the section News and Research,
Further Frequently Asked Questions (FAQ) can be found in the FAQ section of the website.
Bibliography / References
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