Shoulder Pain Management

Frozen Shoulder

Frozen shoulder, also known as adhesive capsulitis or periarthritis of the shoulder, is a common painful condition associated with loss of shoulder motion. The etiology remains unclear. Regardless, the final outcome is a contracted joint capsule that restricts all planes of glenohumeral motion.

Key Observations
• The characteristic feature is a loss of both active and passive shoulder motion
• Disease may be idiopathic or associated with medical conditions such as diabetes
• Disease may last as long as 18-24 months
• Patients are usually 40 years of age or older
• 70% of sufferers are women

The diagnosis of frozen shoulder is performed by exclusion and should not be made until other intrinsic causes of shoulder pain and stiffness have been ruled out. Most cases of frozen shoulder will resolve. Frozen shoulder is often classified into primary and secondary forms. Primary frozen shoulder is idiopathic, while secondary frozen shoulder is associated with other medical conditions.

Patients traditionally progress through three overlapping clinical phases over a period of 18-24 months. The extended duration of this condition, which may last 2 years and possibly have symptoms linger longer, is a long time for a patient to be sidelined due to pain and shoulder stiffness. Early diagnosis and treatment are key for recovery.

Phase 1: Shoulder is stiff and pain worsens over time. The pain may prevent the patient from achieving restful sleep. This phase may last 3 weeks to 9 months.

Phase 2: Shoulder pain may subside, however the shoulder continues to stiffen. Patients may find overhead movements like reaching for dishes, waving, or brushing hair, to be extremely difficult. This phase may last 4-12 months.

Phase 3: Shoulder pain recedes and a spontaneous but gradual improvement in range-of-motion occurs. This final phase can last from 5-24 months.

Clinical Clues
• Painful shoulder followed by loss of motion
• Initially not responsive to conservative therapy
• In time, pain resolves; stiffness resolves much later
• May take 12 months to recover motion

The key to diagnosis is documenting loss of both active and passive motion. While motion is lost in all planes of glenohumeral motion, near complete loss of external rotation is pathognomonic.¹ Examination and documentation of the range-of-motion in the unaffected shoulder are important for comparison purposes (Fig. 1). Active range-of-motion is assessed with the patient standing and should be recorded in the following planes: forward flexion, abduction, internal and external rotation with the arm at the side and with the arm abducted to 90 degrees. Patients with frozen shoulder will attempt to compensate for the loss of motion with increased scapulothoracic motion or excessive trunk lean.

Figure 1: Globally restricted active and passive range of motion demonstrated by loss of forward elevation and external and internal rotation of the shoulder.²

Significant loss of passive shoulder motion further narrows the diagnosis. Passive range-of-motion should be assessed with the patient supine, which stabilizes the scapula and allows for a more accurate assessment of pure glenohumeral motion. Motion should be recorded in the following planes: forward flexion, abduction, internal and external rotation with the arm at the side and with the arm abducted to 90 degrees.

Limited passive range-of-motion distinguishes frozen shoulder from conditions like massive rotator cuff tears. Both frozen shoulder patients and massive rotator cuff tear patients demonstrate loss of active motion; however, massive cuff tear patients generally have near normal passive motion. Other conditions that may limit passive shoulder motion, such as glenohumeral arthritis, fractures or dislocations, will be apparent on plain radiographs.

Physical Findings

The physical examination is critical in ruling out other shoulder pathology and confirming the diagnosis of frozen shoulder. A careful examination of the cervical spine should be performed to rule out cervical pathology that may cause referred pain to the shoulder. On inspection, the patient’s arm is often held in an adducted and internally rotated position. Mild disuse atrophy of the deltoid and supraspinatus may also be observed. Palpation of the shoulder often reveals diffuse nonspecific tenderness over the entire shoulder girdle.

Clinical Course

The clinical course for frozen shoulder is the gradual return toward normal function that may take 6-12 months and is associated with episodes of pain. After the initial symptoms begin to resolve, persistent effort must be directed to regaining motion.

Know When to Refer
• Fracture
• Anterior and/or posterior dislocation
• Septic shoulder
• Rotator cuff tears
• Patient not responding to conservative treatment after 6 months

The ICD9 code for frozen shoulder is 726.0 (Other affections of shoulder region, not elsewhere classified), 726.0 (Disorders of bursae and tendons in shoulder region, unspecified) and 726.0(Adhesive capsulitis of shoulder).

The information contained on this site is provided for your informational purposes only and represents no statement, promise, or guarantee by DePuy Orthopaedics, Inc. concerning levels of reimbursement, payment or charge. Similarly, all billing codes and revenue codes mentioned above are supplied for information purposes only and represent no statement, promise or guarantee by DePuy Orthopaedics, Inc. that these codes will be appropriate or that reimbursement will be made.

Content in this section is adapted and/or repurposed with permission from:
Lotke, PA, Abboud, JA, Ende, J. Lippincott’s Primary Care Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins; 2008:section 8.
Authors: Abboud, JA, Ricchetti, ET, Tjoumakaris, FP, Yagnik, GP.

Lippincott Williams & Wilkins <http://lww.com>

References