MANAGEMENT GUIDELINE: FROZEN SHOULDER

Frozen shoulder: coined by Codman in 1934

A slow onset of pain felt near insertion of deltoid, inability to sleep on affected side, painful and
restricted elevation and external rotation, with normal radiological appearance25

BACKGROUND
Frozen shoulder / adhesive capsulitis
Common, painful condition of the shoulder
Loss of glenohumeral joint (GHJ) range of motion (ROM) due to contraction of GHJ capsule
Usually characterised into: Primary, Secondary9

Concomitant conditions:
- Diabetes mellitus (DM): 26% of DM patients will have frozen shoulder in their
lifetime (versus 5% of general medical patients)
- Rotator cuff tendinopathy/ tear
- Subacromial bursitis
- Biceps tendinopathy
- Previous surgery
- Previous trauma
- Inflammatory diseases9,21

DEFINITION
Variable, no universally accepted definition
Eg. 1: Pain at the extreme of all motions; Marked loss of active and passive global shoulder
motions; Coupled with 50% loss of ER; Globally restricted GH translation7
Eg. 2: 50% loss of passive movement of the shoulder joint relative to the non-affected side in 1
or more of 3 movement directions (ie. forward flexion, abduction in the frontal plane, ER in 0
degrees of abduction); Duration at least 3 months; Exclusion of secondary causes of frozen
shoulder26
Eg. 3: shoulder pain for at least 3 months; No major trauma; 25% or more loss of shoulder

motion in all planes; Pain with motion (minimum 4/10 scale); Normal findings on GH joint XR;
Absence of secondary causes - arthritis, malignancy, cardiac, infection, coagulation disorders6
Due to the lack of uniformity in diagnostic labelling of shoulder pain, one study compared the
selection criteria of different RCTs to evaluate the uniformity in definitions by searching Medline,
Cochrane with search terms: shoulder, shoulder pain, shoulder impingement, rotator cuff,
bursitis, frozen shoulder, calcifying tendonitis
1

restricted movement of the shoulder should be present, however there was no

consistency regarding: amount of restriction (number of degrees), kind of
restriction (active or passive), and direction of restriction (eg. abduction, ER)
- Strongly suggest abolishment of the use of these labels and to direct future research
towards undivided populations with 'general' shoulder pain20
Another study aimed to achieve a consensus definition for frozen shoulder
- Sent 211 questionnaires to clinical members of ASES (American Shoulder & Elbow
Surgeons)
- Proposed the definition of frozen shoulder is a condition characterised by functional
restriction of both active and passive shoulder motion for which radiographs of the

Found that for adhesive capsulitis, there were 21 RCTs, all of which stated that a

GH joint are essentially unremarkable except for possible osteopenia or calcific

tendonitis, classified into:
Primary
Secondary
Intrinsic - eg. rotator cuff, biceps tendon
Extrinsic - eg. breast surgery, cervical radiculopathy, chest wall tumour,
CVA)
Systemic (eg. DM, thyroid)
Found that 82% support the development of a standard definition and classification

of frozen shoulder27
Probably the best definition: shoulder stiffness/ decreased ROM (with or without pain)

EPIDEMIOLOGY
Similar among different populations
- Caucasian populations: 2-5%;16 3%9
- Asian populations: China 2-5%; Singapore 2-5%;25 Hong Kong 3-5%15
PATHOLOGY
Synovial inflammation and joint capsule fibrosis

Macroscopically: capsule thickening and contraction

Microscopically: fibroblasts and mast cells
Also involved: cytokines, matrix metalloproteinases13

CLINICAL PRESENTATION

Usually presents with decreased shoulder ROM and pain after minor (or no) trauma
A poorly localised, deep ache which affects sleep (unable to sleep on affected side)
Often with trouble reaching overhead, away, and behind
Usually no weakness of upper limb (unless tendinopathy or cervical spine pathology present)
May have crepitus on the affected side
Widely accepted to have 3 phases: (1) Painful (2) Freezing (3) Thawing/ recovery. However, no
evidence to validate this classification: pain and limited ROM can occur in all phases, the phases
are often not step-wise

NATURAL HISTORY

One study looking at the long-term outcome of frozen shoulder in 223 patients using conservative
treatment and found that at 5 years that 60% had normal shoulders (usually before 2 years) and
40% had ongoing symptoms (usually mild). A total of 2% patients had moderate to severe
symptoms (and they usually presented with more severe symptoms)12

COSTS (QOL & ECONOMICS)

One cross-sectional study with 12-month FU in diabetic (n-189) and medical (n=99) SOPDs used
SPADI (Shoulder Pain and Disability Index) and SF-36 and found that: shoulder symptoms are
more common in DM (1 in 3, compared with 1 in 6 of control patients), and that shoulder pain/

disability/ physical QOL are worse among DM patients. However, mental QOL worse in patients
with current shoulder symptoms (independent of DM status)14
Another study looked whether adhesive capsulitis responded better to high-grade (end-range)
mobilisation techniques or low-grade (mid-range). Found that at 3 months, 87% patients in both
groups reported improved shoulder function, however the high-grade mobilisation group had
greater improvements, and fewer treatment sessions required
A follow-on study looked at the cost (in terms of QALY and societal costs) of adhesive capsulitis.
It found that by 1 year, absenteeism rates from work was 7% (same as 'normal' populations)
suggesting that adhesive capsulitis does not provide major problems, at least at work. Health
burden due to adhesive capsulitis was 0.048 QALY (mainly due to impairment of physical
functioning, role limitations and pain). Translating the societal costs due to adhesive capsulitis
into the Hong Kong setting, one case of adhesive capsulitis costs approximately HKD 45,000 (of
which 47% constitutes health care costs and 53% non-health care costs - eg. absenteeism and
inefficiency, domestic help and informal care). In Hong Kong, with approximately 3% incidence
of adhesive capsulitis and seven million inhabitants, societal costs amount to approximately HKD
1350 per HK inhabitant annually)
3

The authors recommend that although adhesive capsulitis is a self-limiting disease, given the
burden both to patient and society, effective early treatment of adhesive capsulitis is warranted to
attempt acceleration of recovery. However it is necessary to keep in mind that economic analysis
does not allow for an evidence-based recommendation on the preferred treatment22

DIFFERENTIAL DIAGNOSES9
Condition

P/E

Other

Tests

ACJ arthropathy

Scarf sign +ve

GHJ ROM preserved

Pain localised to ACJ

Hx weight lifting

XR

Autoimmune

Malar rash

Multi-system

ANA

(eg. SLE, RA)

Synovitis in other jt
(tenderness, effusion)

Multiple joints

RF

Biceps tendinopathy Tender long head biceps

tendon
Speed test +ve

Localised anteriorly

None
MRI for Ca2+

C-spine degeneration Neck painful ROM

Weak intrinsic hand ms

Localised posteriorly
Hand numb/weak

C-spine XR

GHJ OA

Similar to frozen shoulder

May have wasted shoulder
girdle ms

Trauma/ Surgery Hx
Older age

XR

Neoplasm

Similar to frozen shoulder

Fever, night sweat, weight

XR
loss, SOB, cough (Pancoast) MRI

Rotator cuff

Painful arc.
+ve

Overuse

MRI

Subacromial/
subdeltoid bursitis

Passive ROM preserved

Overuse

MRI
Subacromial LA

Impingement

RED FLAG
Consider sinister causes if any of the following are present:

fever, night sweat, weight loss

Forearm/ hand neurological symptoms suggest cervical radiculopathy

PHYSICAL EXAMINATION

Usually normal appearance (may have loss of arm swing and /or muscle atrophy in advanced
cases)
On palpation, there is vague diffuse tenderness (focal tenderness is rare and may suggest rotator
cuff tendinopathy)
Patients often have loss of ROM (especially in external rotation), however power is usually
normal (unless concomitant conditions, advanced frozen shoulder or pain-related)

SPECIAL TESTS

Abduction: standing with hands by side; raised arms above head 15 anterior to body; normal
range 0-180

External rotation (or hand to neck): normal range 0-90

Internal rotation: Apley scratch test; compare to normal side
Other tests may be indicated to rule out other conditions, including
- ACJ pathology (usually arthritis): scarf test, forced adduction test, O'Brien's test
- Shoulder tendinopathy: Empty Can Test, Hawkin's-Kennedy Test
- Biceps tendonitis: Yergason's Test, Speed's Test

CLINICAL PREDICTION
One study looked at the effectiveness of ER test for diagnosis of adhesive capsulitis

Found that ER test +ve most sensitive for (1) Adhesive capsulitis, (2) GHJ arthritis (on XR)
Concluded that with a history of atraumatic shoulder pain, ER test +ve should be considered as
adhesive capsulitis in the absence of GHJ arthritis24

INVESTIGATIONS
Gold standard is direct surgical observation
Usually clinical diagnosis is adequate
Investigations may be considered to rule out secondary causes:
- Blood tests: FBG to rule of DM. Note ESR/CRP are usually elevated and are
non-specific (and therefore not indicated)
-

Imaging: (1) X-ray: GHJ OA, fracture, AVN, calcifications (2) MRI:
pathology, tendinopathy, bursitis

rotator cuff

MANAGEMENT

Non-drug
Drug

NON-DRUG
ALLIED HEALTH
One Taiwanese study investigated whether there are kinematic predictors of response to physical
therapy by measuring full active ROM in 3 tests (abduction in scapular plane; Hand-to-neck;
Hand-to-scapular) followed by standardized physiotherapy treatment (including
mobilisation/stretching, USG, diathermy, and electrotherapy). They found at if either of scapular

tipping >8.4 degrees during arm elevation or ER > 39 degrees during hand-to-neck were present,
then the subject would have a 56% improvement in symptoms after three months of physiotherapy.
If both factors were present, then the subject would have a 92% improvement in symptoms26
A Cochrane review looked at the efficacy of different physiotherapy interventions for disorders
resulting in pain, stiffness and/or disability of the shoulder. Twenty-six trials were reviewed,
which had variable methodology and small population sizes. It concluded that laser therapy
might be more effective than placebo in the short term, and that there was no evidence of the
effect of USG. However, overall there was little evidence to guide treatment11
One randomized trial looked specifically at the effectiveness of therapeutic USG in the treatment
of adhesive capsulitis. Deep heat modality has been used for musculoskeletal injuries since
1940s, the rationale being that collagen and tendon extensibility increases as the temperature
increases; stretching should begin during heating and continue as the tissue cools. USG has had
proven effectiveness in treating ROM in arthritic shoulders and calcific tendonitis of the shoulder.
However, at the time of study there was no evidence of effect in other forms of shoulder pain,
including capsulitis, bursitis, and tendonitis. The study randomised patients to either an USG or
sham-USG group. It was found that shoulder ROM, pain and physical QOL improved
significantly in both groups after treatment and after 3 months, and that there was no difference in
pain, and shoulder disability between the two groups. They concluded that USG compared with
sham USG gives no benefit in the treatment of adhesive capsulitis6

ACUPUNCTURE

1st mentioned as treatment for frozen shoulder in 1979

Confers an analgesic effect, for which the hypotheses include:
- Release of beta-endorphins in the lumbar spine and increased 5-hydroxytryptophan in the
cerebrum
- Overriding of the pain stimulus by the biochemical lines of acupuncture in the
transmitting process of the CNS
- Freeing of blockage of qi (energy flow) or a stagnation of blood by acupuncture23
However, there is poor reporting on methods used and varying results to the effectiveness of
acupuncture19
One study aimed to assess the therapeutic outcomes of combining acupuncture and physical
therapy to treat frozen shoulder. It found that all patients had improved QOL after treatment,
pain controlled better by acupuncture, ROM improved better with physical therapy, however best
outcomes with combined treatment. It was recommended that there is integration of Chinese and
Western medicine in the future17
A Cochrane review looked at the efficacy and safety of acupuncture in the treatment of adults with
shoulder pain. There were a total of nine (poor quality) trials. One small pilot study
demonstrated some benefit of both traditional/ ear acupuncture plus mobilisation over
mobilisation alone, however there was not enough evidence to say whether acupuncture works to
treat shoulder pain or whether it is harmful. In addition, almost no trials measure disability
associated with shoulder disorders and disability may in fact be the most important endpoint10

DRUGS
Oral steroids were first used in the 1950s, when anecdotal evidence suggested expedited recovery
and reduced need for manipulation under anaesthesia with oral steroid use. One Cochrane
review looked at efficacy and safety of oral steroids for adhesive capsulitis, and found that overall
the studies were poorly designed and of small size. The only findings was that a three-week
course of 30mg prednisolone daily may provide short-term benefit (<6 weeks) compared to
placebo or no treatment. However, two trials noticed a rebound effect after cessation of steroids.
Therefore, given the potential side effects of oral steroids (eg. lipids, HT), a risk-benefit analysis
should be performed for each patient4

A Cochrane review looked at efficacy and safety of corticosteroid injections in the treatment of
adults with shoulder pain. It found that for adhesive capsulitis
- There was a benefit of injection over analgesia alone up to 6 weeks (unblinded, results
only displayed graphically)
- There was an early benefit of injection with respect to pain and ROM vs no treatment
(only outcome assessment blinded, statistical analyses unclear)
- No difference between high and low dose steroid with respect to improvements in sleep
disturbance, functional impairment or improvement in ER (trend towards high-dose in
pain improvement at 6 weeks)
- There was higher accuracy with anterior injection approach
- Injection better than physiotherapy alone in reducing pain
-

There were no difference between steroid injection and physiotherapy plus NSAID at 2
and 12 weeks (no blinding)
There was no difference between steroid injection and capsular distension, and between
steroid injection and MUA
The study concludes that injections may be beneficial in the short-term for adhesive
capsulitis but the effect may be small and not well-maintained3

WHEN TO REFER

Little or no improvement after 6-12 weeks of conservative treatment

Those who improve but then plateau at an unacceptable level9
Suspect secondary or sinister cause

ORTHOPAEDIC TREATMENT
If patients are referral to orthopaedic specialists, they may expect further management to include:
- Arthrographic distension: might be effective in terms of benefits in pain, range of
movement and function (however, based on a small number of RCTs with small sample
size and poor methodological quality). It is unclear whether this is better than
alternative interventions2
-

Manipulation under anaesthesia has lack of evidence support or refuse its use19

CURRENT GUIDELINES

There are no widely accepted management guidelines on the management of frozen shoulder
One evidence-based guideline on shoulder injuries & related disorders found little evidence to
support or refute the efficacy of common interventions for shoulder disorders in general. It was
suggested that for frozen shoulders, intra-articular corticosteroid injection should be considered
and refer for supervised exercise after acute pain has settled. However, in general, there is a
dearth of good evidence18
Another study looked at the effectiveness of interventions in primary frozen shoulder, however
found insufficient evidence to draw firm conclusions about the effectiveness of treatments
commonly used in the management of frozen shoulder19

SUMMARY

Presentation: often atraumatic shoulder pain and/or stiffness, with external rotation being
particularly affected on physical examination

May consider XR if suspect GHJ arthritis, otherwise no investigations are indicated

Frozen shoulder has a cost both to the individual and to society as a whole
May be useful: physical therapy & NSAIDs together, steroid injection, oral steroids (short-term
relief, significant side-effects), physical therapy and acupuncture together

Not useful: USG alone

Lack of evidence: acupuncture alone, arthroscopic distension, MUA

REFERENCES
1. Batra et al. Comparison of acupuncture and placebo in the treatment of chronic shoulder pain.
American J of Acupuncture 1985;13(1):69-71.
2. Buchbinder et al. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane
Database Syst Rev 2008;1:CD007005.
3. Buchbinder et al. Corticosteroid injections for shoulder pain (review). Cochrane Database Syst Rev
2003;1:CD004016.
4. Buchbinder R et al. Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev
2006;4:CD006189.
5. Cleland J & Durall CJ. Physical therapy for adhesive capsulitis: a systematic review.
Physiotherapy 2002;88:450-7.
6. Dogru et al. Effectiveness of therapeutic ultrasound in adhesive capsulitis. Joint Bone Spine
2008;75:445-450.
9

7. Dudkiewicz et al.

Idiopathic adhesive capsulitis: long-term results of conservative treatment.

IMAH 2004;6:524-526.
8. Erol et al. Shoulder rotator strength in patients with stage I-II subacromial impingement:
relationship to pain, disability and quality of life. J Shoulder Elbow Surg 2008;17:893-897.
9. Ewald A. Adhesive capsulitis: a review. AFP 2011;83(4):417-422.
10. Green et al. Acupuncture for shoulder pain. Cochrane Database Syst Rev 2005;2:CD005319.
11. Green et al. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev
2003;2:CD005319.
12. Hand. Long term outcome of frozen shoulder. J Shoulder Elbow Surg 2008; 17(2): 231-6
13. Hand. 2005 SECEC/ESSSE meeting Rome 2005; Sept (in Lubiecki 2007)
14. Laslett LL et al. Musculoskeletal morbidity: the growing burden of shoulder pain and disability
and poor quality of life in diabetic outpatients; Clin Exp Rheumatol 2007 May-Jun;25(3):422-9.
15. Leung. J Rehabil Med 2008; 40: 145150.
16. Lubiecki. J Orthop Surg (Hong Kong) 2007; 15(1): 1-3.
17. Ma T et al. A study on the clinical effects of physical therapy and acupuncture to treat spontaneous
frozen shoulder. Am J Chin Med 2006;34(5):759-75.
18. Robb G et al. Summary of an evidence-based guideline on soft tissue shoulder injuries and related
disorders - Part 2: Management. J Prim Health Care 2009 Mar 1(1):42-9.
19. Rookmoneea M. The effectiveness of interventions in the management of patients with primary
frozen shoulder. J Bone Joint Surg (Br) Sept 2010;92B(9):1267-72.
20. Schellingerhour JM et al. Lack of uniformity in diagnostic labelling of shoulder pain: time for a
different approach. Manual Therapy 2008;13:478-483.
21. Thomas. J Shoulder Elbow Surg 2007; 16(6): 748-51.
22. Van den Hout et al. Impact of adhesive capsulitis and economic evaluation of high-grade and
low-grade mobilisation techniques. Aus J of Physiotherapy 2005;51:141-149.
23. Viola L. A critical review of the current conservative therapies for tennis elbow (lateral
epicondylitis). ACO 1998;7(2):53-67.
24. Wolf EM, Cox WK. The external rotation test in the diagnosis of adhesive capsulitis.
Orthopedics. 2010 May 12;33(5)
25. Wong PLK & Tan HCA. A review on frozen shoulder. Singapore Med J 2010;51(9):694-697.
26. Yang et al. Shoulder kinematic features using arm elevation and rotation tests for classifying
patients with frozen shoulder syndrome who respond to physical therapy. Manual Therapy
2008;13:544-551.
27. Zuckerman JD & Rokito A. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg
2011;20:322-325

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Shoulder stiffness / decreased ROM (+/- pain)

Clinical assessment
History

Examination

ROM details: trouble reaching overhead, behind back

Normal appearance (unless advanced: loss arm

Pain details: location (deep, poorly localized)

swing, muscle wasting)

Progression of symptoms

Vague diffuse tenderness on palpation

Sleep: affecting sleep, unable to sleep on affected side

Loss of ROM, especially in ER

Previous shoulder trauma or surgery

2 causes:

DM, tendinopathy, bursitis, inflammatory

Investigations

disease, limb weakness/numbness

Red flag: weight loss, fever, night sweat

Usually not indicated

Contraindications to therapy: eg. NSAIDs

May consider to exclude 2 causes:

- FBG (DM)
- XR (OA, #, AVN, calcifications
- MRI (cuff, tendinopathy, bursitis)

Consider 2 cause1
Frozen shoulder

Neoplasm

GHJ OA

Rotator cuff

Bursitis (subacromial, subdeltoid)

Autoimmune

ACJ arthropathy

Biceps tendinopathy

C-spine

Diagnose frozen shoulder

Education on natural history2
By 2 years, 60% have asymptomatic shoulders, 40% with persistent symptoms (mostly mild)
By 2 years, only 2% have symptoms that interfere with work or ADL

Management
Non-drug

Drug

Useful: laser3, acupuncture4,5, physio (with NSAID).

Not useful:

physio alone, USG alone

Useful:

steroid injection7, NSAID

plus physio, oral steroids

11

Other

Not useful: arthroscopic

distension9, MUA10

Consider referral1
No improvement at 6 weeks of conservative therapy / plateau at unacceptable level
Suspect secondary or sinister cause

REFERENCES
1.

Ewald A. Adhesive capsulitis: a review. AFP 2011;83(4):417-422

2. Hand.

Long term outcome of frozen shoulder. J Shoulder Elbow Surg 2008; 17(2): 231-6

3. Green et al. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev 2003;2:CD005319.
4. Ma T et al. A study on the clinical effects of physical therapy and acupuncture to treat spontaneous frozen shoulder.
Am J Chin Med 2006;34(5):759-75.
5. Green et al. Acupuncture for shoulder pain. Cochrane Database Syst Rev 2005;2:CD005319.
6. Dogru et al. Effectiveness of therapeutic ultrasound in adhesive capsulitis. Joint Bone Spine 2008;75:445-450.
7. Buchbinder et al. Corticosteroid injections for shoulder pain (review). Cochrane Database Syst Rev
2003;1:CD004016.
8. Buchbinder R et al. Oral steroids for adhesive capsulitis.

Cochrane Database Syst Rev 2006;4:CD006189.

9. Buchbinder et al. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev
2008;1:CD007005.
10. Rookmoneea M. The effectiveness of interventions in the management of patients with primary frozen shoulder. J
Bone Joint Surg (Br) Sept 2010;92B(9):1267-72.

12

13

28. .

14