Maturitas 78 (2014) 11–16

Contents lists available at ScienceDirect

Maturitas
journal homepage: www.elsevier.com/locate/maturitas

Review

Frozen shoulder – A stiff problem that requires a flexible approach

P.M. Guyver a,∗ , D.J. Bruce a , J.L. Rees b
a
Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX37HE, United Kingdom
b
Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, The Botnar Research Institute, University of Oxford, Old Road,
Headington, Oxford OX37LD, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Frozen shoulder is a specific, painful and debilitating condition effecting patients mainly in middle age.
Received 11 February 2014 While it has been recognised for over 100 years, it is still mis-diagnosed, with a natural history that is
Accepted 14 February 2014 poorly understood and with limited evidence for the efficacy for various treatments. This review considers
what is known about this common painful condition and the treatments available.
Keywords: © 2014 Elsevier Ireland Ltd. All rights reserved.
Frozen shoulder
Adhesive capsulitis
Manipulation
Arthroscopic release
Hydrodilatation

Contents

1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.1. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.2. Natural history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.3. Pathoanatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2. Clinical assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.1. History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.2. Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.3. Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.4. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3. Conservative treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.1. Physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.2. Intra-articular steroid injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.3. Intra-articular sodium hyaluronate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.4. Oral steroid therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.5. Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4. Interventional treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4.1. Distension arthrography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4.2. Surgery – manipulation under anaesthetic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
4.3. Surgery – arthroscopic capsular release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

∗ Corresponding author at: Clinical Fellow in Shoulder and Elbow Surgery, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX37HE, United Kingdom.
Tel.: +44 1865 741155; fax: +44 1865 738056.
E-mail addresses: Paul.guyver@nhs.net (P.M. Guyver), Davebruce84@gmail.com (D.J. Bruce), jonathan.rees@ndorms.ox.ac.uk (J.L. Rees).

http://dx.doi.org/10.1016/j.maturitas.2014.02.009
0378-5122/© 2014 Elsevier Ireland Ltd. All rights reserved.
12 P.M. Guyver et al. / Maturitas 78 (2014) 11–16

Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Clinical presentation is classically in three overlapping phases

Box 1: British Elbow and Shoulder Society (BESS) [9]:
survey-definition of frozen shoulder [8]
Definition of Frozen Shoulder • Phase 1: Lasting 2–9 months; Painful phase or pain predominant
Symptoms True (deltoid insertion) shoulder pain phase, with progressive stiffening and increasing pain on move-
Night pain of incedious onset ment.
• Phase 2: Lasting 4–12 months; Stiffening, freezing or stiffness pre-
Signs Painful restriction of active and passive motion
Passive elevation less than 100◦ dominant phase, where there is gradual reduction of pain but
Passive external rotation less than 30◦ stiffness persists with considerable restriction in range of motion.
Passive internal rotation less than L5 • Phase 3: Lasting 12–42 months; Resolution or thawing phase,
All other shoulder conditions excluded
where there is improvement in range of motion with resolution
Investigations Plain radiographs normal of stiffness.
Arthroscopy shows vascualr granulation tissue in the
rotator interval
While frozen shoulder has been recognised for over 100 years,
there still remains a lack of reliable evidence on the natural and
variable history of this condition. In addition there is a lack of
up to date high quality studies dealing with the variety of treat-
1. Background ment options available. As such, it is sensible to involve patients in
shared decision making about their treatment. We recommend a
Frozen shoulder is an extremely painful and debilitating condi- ‘flexible’ approach to frozen shoulder management, tailoring treat-
tion leading to stiffness and disability. The prevalence of shoulder ment choices to the needs of each individual patients dependent on
complaints in the UK is estimated to be 14%, with 1–2% of adults factors such as symptom severity, age, occupation, patient require-
consulting their general practitioner annually regarding new-onset ments and longevity of symptoms.
shoulder pain [1]. Many of these patients may have apparent or
true ‘stiffness’. Apparent stiffness can occur either through muscle 1.1. Epidemiology
weakness (such as a rotator cuff tear) or through pain inhibition,
whereas ‘true’ stiffness from frozen shoulder has characteristic Frozen shoulder is estimated to affect 2–2.4% of the general
features of pain and physical restriction of movements of the gleno- population [10,11], with a cumulative incidence of 11.2 per 1000
humeral joint (ball and socket), in the presence of normal X-rays. person-years [12]. It typically occurs in the 5th and 6th decades of
This important difference is often not appreciated and frequently life, thus affecting individuals of working age. It is rare before the
leads to an over and misdiagnosis of frozen shoulder [2,3]. Reasons age of 40 years and is unusual in patients over 70 years. Women are
for this range from education; variations in definition and clearly marginally more affected than men [13–15]. 20% of contralateral
defined diagnostic criteria; common inaccurate terms used along- shoulders can develop similar problems but bilateral simultaneous
side frozen shoulder. Frozen shoulder has also been referred to as frozen shoulder is rare. Recurrence in the same shoulder is also very
periarthritis, retractile capsulitis, adhesive capsulitis, and steroid- rare [14–16]. There is no current evidence to suggest a racial pre-
sensitive arthritis. These terms indicate a false pathology of the disposition but there is some evidence of a genetic link with twins
condition and are misleading. The pathology of this condition is a having up to a threefold increased risk [17].
soft tissue fibrosing and inflammatory one. There are no ‘adhesions’ The incidence of frozen shoulder in people with diabetes is
within the joint. higher and reported to be 10–36% with a combined prevalence of a
More recently, there has been an acknowledgement of the diabetic predisposition and frozen shoulder estimated to be as high
absence of a specific definition [5,6] and of diagnostic criteria for as 71.5%. Diabetics have a 2–4 times greater risk and a 10–20% life-
this condition [6] which both the British Elbow and Shoulder Soci- time risk of developing frozen shoulder compared to the general
ety (BESS) and American Shoulder and Elbow Surgeons (ASES) have population and more importantly their disease course is usually
endeavoured to rectify. These societies tried to improve on the long more severe and protracted [9,11,18–20].
established definition of Codman [7] who described the common
features of a slow onset of pain felt near the insertion of the del- 1.2. Natural history
toid muscle, inability to sleep on the affected side with restriction
in both active and passive elevation and external rotation, yet with The natural and apparent variable history of this condition is
normal radiographic appearance. A survey of the members of BESS poorly understood. Many studies suggest that frozen shoulder is
overwhelmingly agreed with the definition of frozen shoulder as a self-limiting condition, with most cases recovering within 2–3
seen in Box 1 [8]. years [7,21], while others indicate a proportion of patients that do
Frozen shoulder can be either primary (idiopathic – as in there not regain full shoulder motion [9]. It has been suggested that up to
are no detectable underlying cause) or secondary. Secondary frozen 40% of patients may experience persistent symptoms with 7–15%
shoulder is defined as that associated with trauma, cardiovascular having some degree of permanent loss of movement [22,23]. How-
disease, hemiparesis or diabetes. The ASES and Robinson et al. [2,6] ever the majority of these symptoms are usually mild and cause
collectively agreed that frozen shoulder should be classified into limited functional loss [22,24]. The two most comprehensive nat-
primary and secondary types with secondary diabetic frozen shoul- ural history studies are by Hand et al. [22] and Shaffer et al. [25].
der being considered as a separate type since their disease course Hand et al. [22] published the largest series of 223 patients with a
is usually more severe and protracted. mean follow up of 4.4 years showing that 59% made a full recovery
 P.M. Guyver et al. / Maturitas 78 (2014) 11–16
whilst 35% had mild to moderate symptoms with pain being the
most common complaint and 6% had severe symptoms at follow
up. 20% reported bilateral symptoms, but there were no recurrent
cases. Shaffer et al. [25] evaluated 62 patients with a mean follow
up of 7 years demonstrating 50% of patients were reported to still
have some mild pain and 60% had some ongoing stiffness mostly
in external rotation although again this caused limited functional
impairment.
1.3. Pathoanatomy
Frozen shoulder can be described pathologically as a fibrotic
inflammatory contracture of the rotator interval, capsule and liga-
ments. It is therefore a soft tissue problem and not a boney one.
It limits gleno-humeral joint movement by the thickening and
shortening of these tissues. Macroscopically at arthroscopy (key-
hole surgery), the capsule is thickened and inflamed with vasculitic
‘frond’ like projections (villonodular synovitis) in the rotator inter-
val (front and upper part of the shoulder). This progresses to a more
glass like fibrotic appearance over time. Historically, Neviaser [4],
DePalma [26] and Neer [27] all described the same arthroscopic
findings of frozen shoulder with thickening and shortening of the
soft tissues in and around the rotator interval.
Cadaveric studies confirmed these findings and concluded that
the rotator interval played an important role in gleno-humeral
motion and stability. In particular plication of the anterosuperior
capsular caused selective restriction of external rotation with an
adducted arm, characteristic of frozen shoulder [28,29]. Other stud-
ies have further supported these results demonstrating that the
structures primarily involved are the coracohumeral ligament, the
rotator interval (comprising of the superior gleno-humeral liga-
ment and the rotator interval capsule), the anterior capsule and
the inferior gleno-humeral ligament [30–32].
While histological studies of the capsule have confirmed signifi-
cant increases in fibroblasts myofibroblasts and inflammatory cells
including mast cells, T cells, B cells and macrophages [15], there
remains disagreement about the underlying pathological process.
Opinions vary from an inflammatory cause, to fibrosis or even an
algo-neurodystrophic process.
2. Clinical assessment
2.1. History
Frozen shoulder is a clinical diagnosis with characteristic signs
and symptoms. Therefore a thorough history and physical exami-
nation are required to establish an accurate diagnosis. It is a rare
diagnosis before the age of 35 years and is unusual in patients over
70 years, with women marginally more affected than men [13–15].
Frozen shoulder needs to be considered in diabetics with shoulder
pain and restricted movement due to their high reported incidence
of this condition being 10–36%. The pain is characteristically felt
around the deltoid insertion but also diffusely around the shoul-
der. A patient usually describes the pain as severe, wakes them at
night and interferes with their normal daily activities [33,34]. The
pain can radiate down the arm and it seems to pass through three
distinct phases as described above [35].
2.2. Examination
You will usually find global loss of all gleno-humeral move-
ments. In particular, loss of passive external rotation, both with
the arm in neutral and in abduction is usually a pathognomonic
sign of frozen shoulder. Most clinicians would agree that exter-
nal rotation should be reduced by more than 50% compared to the
unaffected side to consider a diagnosis of frozen shoulder. There
13
are other causes of loss of external rotation, but these bony causes
can be ruled out with plain radiographs of the shoulder (arthritis,
locked posterior dislocation, malignancy).
2.3. Investigation
As early as 1934 [7] Codman indicated the importance of a nor-
mal radiograph in confirming a diagnosis of frozen shoulder and
this still stands true today. To diagnose this soft tissue problem,
a normal X-ray of the gleno-humeral joint is needed to exclude
the bony causes of pain and restricted movement. There is no cur-
rent evidence to support USS and MRI studies in reliably diagnosing
frozen shoulder.
2.4. Treatment
Recently a full evidence synthesis and systematic review
assessing treatments for frozen shoulder was conducted. It con-
cluded that there was limited clinical evidence and economic
evidence on the effectiveness of treatments for primary frozen
shoulder [36]. In addition the authors concluded that there is cur-
rently no formal consensus on the optimal management of frozen
shoulder with different groups of healthcare professionals favou-
ring different treatment pathways and thus further high-quality
primary research is required [37]. The following section highlights
the current best evidence or consensus for both conservative and
interventional treatments of frozen shoulder.
It must be remembered that most patients can be managed with
non-operative treatment, often in the primary care setting, utilising
a multidisciplinary approach. Secondary frozen shoulder tends to
be more refractory to conservative management and interventional
approaches can be used earlier [2].
3. Conservative treatment
Conservative options such as education and analgesia, physical
therapy or in combination with an intra-articular steroid injection
were found to be the most common non-surgical treatment options
for idiopathic frozen shoulder offered by UK healthcare profes-
sionals [37]. While there is a lack of evidence in the form of high
quality randomised controlled trials (RCTs) to support these com-
mon treatment options [36], they are non-interventional, cheap
and come with minimal risk. However, what is important to focus
on in the early stages of this condition is how to relieve pain. The
combination use of appropriate analgesia, patient education and
some active exercises seems to help relieve pain, reduce frustration
and improves patient compliance towards treatment [38]. A single
quasi-experimental study favoured ‘supervised neglect’ as a treat-
ment modality verses intensive physiotherapy. However, the lack
of randomisation, small sample size and short follow-up precluded
any firm conclusions [39].
3.1. Physical therapy
Physical therapy encompasses various techniques, such as
physiotherapy and osteopathy, and various modalities, includ-
ing ultrasound and laser therapy. The recent NIHR commissioned
systematic review identified ten RCTs that assessed physical mobil-
isation therapies either against a control group or alternative
physical therapies. However, the overall quality of data available
was poor with only one of these studies being of satisfactory rigour
[36].
A six- to twelve-week course of physiotherapy is commonly pre-
scribed for many patients suffering with shoulder pain with the aim
of improving limitations in range of movement. This may involve
passive mobilisation and capsular stretching. However this may be
14 P.M. Guyver et al. / Maturitas 78 (2014) 11–16
inappropriate for a patient during the acute inflammatory painful
phase of frozen shoulder with many patients finding this painful
[2]. The evidence for any particular physical treatment modality
is lacking [36]. An RCT of 100 patients compared physiotherapy
using high-grade mobilisation techniques (where mobilisation is
applied with greater intensity) to low grade mobilisation tech-
niques (where the joint is mobilised only in a pain-free range).
While it concluded that high-grade techniques more effectively
improved mobility of the gleno-humeral joint and led to reduced
disability, the differences between the groups was small with only
a minority of outcome measures reaching clinical significance and
there was no control group [40].
The use of physical therapies involving heating tissues as
adjuncts to mobilisation has been reported in several studies. The
rationale is that the viscoelastic properties of the connective tissues
are changed. There are various techniques for achieving deep tissue
heating, including ultrasound and shortwave diathermy. Ultra-
sound is also postulated to produce mechanical effects. Shortwave
diathermy in combination with stretching compared to stretching
alone found some improvements in pain relief and disability in a
small RCT [38].
Overall, the evidence is limited with no particular physical ther-
apy shown to be superior.
3.2. Intra-articular steroid injection
Intra-articular corticosteroid injections are given to help reduce
inflammation and provide analgesia. While their use has been eval-
uated in several RCTs, a criticism of most trials is that steroid
injection was frequently administered in combination with other
treatments and control groups were therefore not adequate [36].
An RCT of 93 patients, comparing a single injection of tri-
amcinolone hexacetonide with or without physiotherapy against
placebo, found that corticosteroid injection in combination with
a home exercise programme improved shoulder pain and range
of motion at three months. The addition of a supervised physio-
therapy programme led to more rapid improvements in range of
motion but supervised physiotherapy alone provided limited ben-
efit. However, by 12 months, the outcomes were similar regardless
of the treatment provided [41].
3.3. Intra-articular sodium hyaluronate
Sodium hyaluronate, a component of connective tissue, has
been investigated as a treatment for osteoarthritis. It is thought
to affect the metabolism of articular cartilage and synovial tissue.
Some studies reported to show some benefit and have suggested
its use as an alternative treatment [42]. However, the few RCTs of
this treatment modality do not show consistent evidence of ben-
efit compared to physical therapy or steroids and the treatment
is not licensed for use in frozen shoulder. Consequently, it is not
commonly used [36].
3.4. Oral steroid therapy
A systematic review in 2006 identified five RCTs, which indi-
cated that oral steroids provide improvements in pain, range of
movement and function but only for a period of less than six week
[43]. This is not a recommended or commonly prescribed treatment
in the UK [36].
3.5. Acupuncture
Acupuncture is said to act by stimulating endogenous opioid
secretion and inhibiting the transmission of pain signals to the brain
[44]. A Cochrane review including nine studies suggested a possi-
ble short-term benefit for pain and function. However, there was
evidence that other pain-control measures, such as supra-scapular
nerve block, were more effective [44,45]. The data available is at
high risk of bias and provides only short-term follow up. It is there-
fore not possible to make any firm conclusions about the efficacy
of acupuncture for frozen shoulder [36].
4. Interventional treatment
The most frequent indications for invasive treatments are per-
sistent and severe functional restrictions that are resistant to
conservative measures. However, the data from high-quality RCTs
of invasive interventions is even more limited than for conservative
interventions.
4.1. Distension arthrography
This procedure is performed under fluoroscopic guidance (or
USS) by an interventional radiologist, and does not require general
anaesthesia. A characteristic contracted arthrogram appearance
is initially confirmed before local anaesthetic is injected into the
joint. Sterile water is then injected under pressure with the aim
of stretching the fibrotic joint capsule. Many radiologists feel that
this technique can cause the required capsular rupture that surgery
achieves. This technique is usually then always completed with an
intra-articular injection of steroid. Physiotherapy is usually com-
menced immediately after the procedure in order to maintain any
improved range of movement.
In the extended literature there is limited evidence of clinical
benefit from capsular distension with only mild or no improve-
ments being reported with distension in the short and medium
term when compared with steroid [46,47] or placebo [48] or phys-
iotherapy [49]. Three RCT’s [46–48] were identified by a recent
systematic review [35] with only one being judged of sufficient
quality with the others having a high risk of bias. This study [48]
stated that there was no significant difference in terms of pain,
function and range of movement between arthrographic distension
with steroid and placebo (arthrogram only) at 6 or 12 weeks.
Due to the insufficient evidence available for distension all that
can be concluded is that further trials need to be performed in this
area. However this treatment is still considered an easier and useful
alternative to more interventional procedures such as Manipula-
tion or Capsular Release which are operations requiring general
anaesthetic. Indeed patient preference to avoid surgical procedures
tends to lead to the prescription of this treatment option.
4.2. Surgery – manipulation under anaesthetic
Manipulation under anaesthesia (MUA) can be used alone or in
combination with a steroid injection and/or with an arthroscopic
capsular release. Manipulation is performed with a patient under
a general anaesthetic. The capsule of the gleno-humeral joint is
deliberately torn by controlled manipulation of the arm through
a specific sequence of movements. It is avoided in the elderly or
osteoporotic bone, due to the risk of humeral fracture. It is often
supplemented with an intra-articular injection of steroid and phys-
iotherapy is then prescribed to maintain the improved range of
movement.
Evidence to support MUA remains limited with very few high
quality studies [48] but with underpowered Level 4 evidence sug-
gesting good to excellent results in the long-term [50–53]. Of the
three RCT’s described in the recent systematic review [36], only
one [54] was deemed of sufficient quality with the other two hav-
ing differing risks of bias [55,56]. The study of adequate quality
demonstrated no statistically significant difference between MUA
 P.M. Guyver et al. / Maturitas 78 (2014) 11–16
(and home exercise) compared to home exercise alone in terms of
pain, function and range of motion at 6 weeks, 3, 6 and 12 months
[54].
4.3. Surgery – arthroscopic capsular release
Arthroscopic capsular release [AR] is now becoming the more
common surgical intervention performed for the treatment of
frozen shoulder. The surgery begins with an arthroscopic inspec-
tion of the gleno-humeral joint to confirm the diagnosis and to
identify any coincident pathology. The contracted structures of
the rotator interval (coracohumeral ligament, anterior capsule,
superior and middle gleno-humeral ligaments) are then released
(divided) usually using radiofrequency ablation. The anterior cap-
sule and anterior band of the inferior gleno-humeral ligament are
also divided. At this point the release can normally be completed
with a controlled MUA that requires much less force. Some clini-
cians advocate a further arthroscopic release of the posterior and
inferior capsule or a ‘360-degree’ release [57]. However, great care
has to be taken to avoid iatrogenic injury to the axillary nerve. Phys-
iotherapy is again prescribed to maintain the improved range of
movement.
The evidence to support this intervention is still limited. There
are no RCTs or comparative studies involving arthroscopic capsular
release. There are three case series of over 50 patients supporting
the use of AR that have been reported to date. The three reported
case series of 66 [58], 136 [59] and 183 [60] patients found signif-
icant improvements in pre and post operative pain, function and
range of movement measurements at mean follow up of 10, 12 and
29 months, respectively [58–60].
5. Conclusion
In summary the great frustration with frozen shoulder for both
clinicians and patients, is that despite it being so painful and restric-
tive, we are no further on 100 years after its recognition in providing
evidence based information and treatment. As such, correct diag-
nosis is important and most patients with primary frozen shoulder
are best initially treated symptomatically with pain modifica-
tion and supportive physiotherapy using adjunctive intra-articular
steroid injection when required. However until more evidence from
well constructed trials indicates otherwise, a pragmatic ‘flexible’
approach to the management of frozen shoulder, involving the
patient and their needs is recommended. The degree of symp-
toms encountered does seem to vary greatly between patients
and further highlights the importance of a shared decision mak-
ing approach with the ability to step up treatment to more invasive
options if deemed appropriate. Failures of initial treatment to con-
trol pain, or considerable functional compromise from stiffness, or
doubt about diagnosis are good reasons for referral to specialist sec-
ondary care. It seems distension arthrography is being increasingly
used as a first line of invasive treatment and is being considered
more and more by patients and clinicians before surgical interven-
tion.
Future national multi-centre trials are essential to evaluate the
efficacy of the various treatment options available for frozen shoul-
der but until such time a pragmatic, flexible and escalating model
as alluded to in the text is advised.
Contributors
Paul Guyver: Compilation and revision of research proposal,
literature review, manuscript preparation with revisions and sub-
mission. Approved the final version of the paper. David Bruce:
Literature review and manuscript preparation. Approved the final
15
version of the paper. Jonathan Rees: Review of research proposal,
finalising research proposal, provision of expert opinion, final
manuscript review and final editing. Approved the final version of
the paper.
Competing interests
The authors declare no conflict of interest.
Funding
The authors have received no funding for this article.
Provenance and peer review
Commissioned and not externally peer reviewed.
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