Frozen Shoulder  /  Further Readings and References

Incidence:

It has been reported to be between 2% to 5% of the general population. It most commonly affects women aged between 40 and 60 years. Frozen shoulder often presents bilaterally and commonly affects the contralateral side years after onset of symptoms in the first shoulder.

 

Types:

  • Primary 
    Onset is generally idiopathic (it comes on for no attributable reason).

  • Secondary 
    Results from a known cause, predisposing factor or surgical event. A secondary frozen shoulder can be the result of several predisposing factors. For example, immobilisation, post surgery, post-stroke and post-injury.

 

Assoications:

  • Diabetes 

  • Hypothyroidism 

  • Metabolic syndrome 

  • Dupuytren contracture
    Multiple authors have identified an association between Dupuytren contracture and frozen shoulder. Smith et al 97 reported that Dupuytren disease is 8.27 times more common in patients with frozen shoulder compared with the general population, however, this strong association is not well understood.

  • Hypoparathyroidism

 

Phases:

Capsulitis has been described as having three characteristic phases. During the first painful phase, the shoulder complex is severely painful, often during rest, and this phase can last anything from 3 to 6 months. Subsequently, during the adhesive phase, pain resolves but significant restriction of movement, active and passive, occurs in all planes. In the final resolution phase, recovery of function is said to occur. The transition through these stages is thought to take an average of 30 months, but may be considerably longer and it is not clear that complete recovery occurs: one study found that as many as 50% of patients failed to regain a normal range of movement, even at follow-up after 7 years.

- Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder: a long term follow up. J Bone J Surg. 1992; 74-A:738–746.

Treatment options:

  • Oral analgesia and watchful waiting.

  • Physiotherapy
    Typically combinations of advice and education, exercises, manual therapy, thermotherapy, and electrotherapy. Care packages may also include acupuncture or corticosteroid injections.

  • Acupuncture.

  • Oral corticosteroid.

  • Intra-articular corticosteroid injections.

  • Hydrodilatation (injection of up to 40mL of sterile saline solution, usually with corticosteroid, to distend the shoulder capsule).

  • Manipulation of the shoulder joint under general anaesthesia.

  • Capsular release (surgical procedure, typically arthroscopic, to release contracted tissue)

Pathology and pathogenesis:

Findings at operation
During surgery, one can see inflamed synovia with neoangiogenesis (related to inflammation), and thickened and stiffened joint capsule (related to fibrosis).

Wiley AM. Arthroscopic appearance of frozen shoulder. Arthroscopy 1991;7:138-143.

Histology from biopsy
The cell density is significantly higher and the capsular tissue was significantly stiffer. The pathogenesis of frozen shoulder is still unclear. It has been thought to be a combination of synovial inflammation and capsular fibrosis.  In addition, chondrogenesis is likely to have a critical role in the pathogenesis of frozen shoulders.

 - Lundberg BJ. The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycans content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl 1969;119:1-59.

 

- Neviaser JS. Adhesive capsulitis of the shoulder: A study of the pathological findings in periarthritis of the shoulder. J Bone Joint Surg Am 1945;27:211-222.

 

- Hagiwara Y, Ando A, Onoda Y, et al. Coexistence of fibrotic and chondrogenic process in the capsule of idiopathic frozen shoulders. Osteoarthritis Cartilage 2012;20:241-249.

Biochemical features
Cytokines and growth factors related to fibrosis and inflammation increased in the joint capsule from frozen shoulder. In addition, tumour necrosis factor-alpha, and platelet-derived growth factor in the capsule and in the synovium has been described.  In particular, capsular fibrosis may result from persistent stimulus of the matrix-bound transforming growth factor-beta.

- Bannwarth B. Drug-induced musculoskeletal disorders.Drug Saf 2007;30:27-46.

- Bowman C, Jeffcoate W, Pattrick M, Doherty M. Case report: Bilateral adhesive capsulitis, oligoarthritis and proximal myopathy as presentation of hypothyroidism. Rheumatology 1988;27:62-64.

- Bridgman J. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis 1972;31:69-71.

- Johnson J. Frozen-shoulder syndrome in patients with pulmonary tuberculosis. J Bone Joint Surg Am 1959;41: 877-882.

- Engelman R. Shoulder pain as a presenting complaint in upper lobe bronchogenic carcinoma: Report of 21 cases. Conn Med 1966;30:273-276.

- Oldham B. Periarthritis of the shoulder associated with thyrotoxicosis. A report of five cases. N Z Med J 1959;58: 766-770.

- Brue S, Valentin A, Forssblad M, Werner S, Mikkelsen C, Cerulli G. Idiopathic adhesive capsulitis of the shoulder: A review. Knee Surg Sports Traumatol Arthrosc 2007;15: 1048-1054.

Genetics
Whether a genetic predisposition for frozen shoulder exists is controversial. Twin studies have shown that adhesive capsulitis occurs 2 to 3 times more frequently than by chance, but this result may be because of individual-specific environmental factors rather than a true genetic component. Studies on human leukocyte antigen B27 (HLA-B27) prevalence in patients with frozen shoulder have been mixed. Interestingly, there are a number of studies reporting a strong association between adhesive capsulitis and Dupuytren disease, which is also believed to have a heritable component.

Disclaimer

The content of this article is intended to give a personal summary of a shoulder condition. It is intended for the exclusive viewing of qualified Australian medical general practitioners only.

 

A medical practitioner should only consider adopting or recommending the opinions of the author and proposed approach for the treatment of patients covered in this article, after performing normal clinical practice. This should include a thorough medical history, assessment, and detailed clinical examination supported with relevant scans and other medical tests.

 

In all cases, it is up to the individual medical practitioner to exercise his/her own discretion to determine the appropriateness of adopting or recommending the opinions and approach of the article for the treatment of patients. 

 The contents of the article cannot and does not purport to provide an exhaustive detailed analysis of this and all shoulder conditions and potential treatments. A further in-depth study from medical textbooks, publications and other medical literature is recommended

 

for each individual shoulder condition. If you are not a medically qualified person, you should seek the advice of your medical practitioner or other qualified health provider with any questions you may have regarding a medical condition.

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