Review Article Clinics in Orthopedic Surgery 2019;11:249-257 • https://doi.org/10.4055/cios.2019.11.3.

249

Treatment Strategy for Frozen Shoulder

Chul-Hyun Cho, MD, Ki-Choer Bae, MD, Du-Han Kim, MD
Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea

Frozen shoulder (FS) is a common shoulder disorder characterized by a gradual increase of pain of spontaneous onset and limita-
tion in range of motion of the glenohumeral joint. The pathophysiology of FS is relatively well understood as a pathological process
of synovial inflammation followed by capsular fibrosis, but the cause of FS is still unknown. Treatment modalities for FS include
medication, local steroid injection, physiotherapy, hydrodistension, manipulation under anesthesia, arthroscopic capsular release,
and open capsular release. Conservative management leads to improvement in most cases. Failure to obtain symptomatic improve-
ment and continued functional disability after 3 to 6 months of conservative treatment are general indications for surgical manage-
ment. However, there is no consensus as to the most efficacious treatments for this condition. In this review article, we provide an
overview of current treatment methods for FS.
Keywords: Frozen shoulder, Adhesive capsulitis, Treatment, Shoulder

Frozen shoulder (FS) is one of the most common, yet cohumeral and middle glenohumeral ligaments (Fig. 1).6)
challenging clinical disorder presenting to the orthopedic Microscopically the affected capsule has a higher number
surgeon. It is a disease characterized by a significant de- of fibroblasts, mast cells, macrophages, and T cells. This
crease of active and passive range of motion (ROM) of the synovitis is associated with the increased fibrotic growth
glenohumeral joint along with pain. The prevalence rate of factors, inflammatory cytokines, and interleukins.7,8)
FS is 2%–5%, and it occurs more commonly in women.1,2) A primary or idiopathic FS occurs when there is no
Along with the increase in the comorbidities and changes exogenous cause or preexisting condition or may be as-
in lifestyle, the incidence of FS is increasing.3,4) But, the sociated with another systemic illness. The most common
natural course and pathogenesis of FS have not been wide- association is diabetes mellitus and the incidence is report-
ly investigated and are still unknown. According to the ed to be 10%–36%.9) Thyroid disease, adrenal disease, car-
research so far, FS can be divided into three phases: freez- diopulmonary disease, and hyperlipidemia are also known
ing (insidious onset of shoulder pain with progressive loss to be related.9) FS with an identifiable traumatic (fracture,
of motion), frozen (gradual subsidence of pain, plateau- dislocation, and soft tissue injury) or nontraumatic (osteo-
ing of stiffness with equal active and passive ROM), and arthritis, rotator cuff tendinopathy, and calcific tendinitis)
thawing (gradual improvement of motion and resolution shoulder pathology are categorized as secondary FS.10)
of symptoms).5) Macroscopic findings include thickening Traditionally, FS has been regarded as a self-limiting
and congestion of the capsule, with an inflamed appear- and benign disease with complete recovery of pain and
ance, particularly around the rotator interval, of the cora- ROM. However, this condition can sometimes last for
years. In one study, 50% of patients were still experiencing
pain or stiffness of the shoulder at a mean of 7 years from
Received April 15, 2019; Accepted April 18, 2019 the onset of the condition, although only 11% reported
Correspondence to: Du-Han Kim, MD functional limitation.11) Reeves5) in a prospective study of
Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung 41 patients with 5 to 10 years’ follow-up, found that only
University School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu 41931, 39% of patients had full recovery. This long period of pain
Korea and disability deprive the patients of their routine life and
Tel: +82-53-258-7930, Fax: +82-53-258-4773
occupational and recreational activities. Although appro-
E-mail: [email protected]
priate treatment is needed for a rapid return to their own
Copyright © 2019 by The Korean Orthopaedic Association
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Clinics in Orthopedic Surgery • pISSN 2005-291X eISSN 2005-4408
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Cho et al. Treatment Strategy for Frozen Shoulder
Clinics in Orthopedic Surgery • Vol. 11, No. 3, 2019 • www.ecios.org

Fig. 1. (A, B) Arthroscopic findings of

frozen shoulder. Inflammatory synovitis
in the glenohumeral joint. (C) Middle
A B C glenohumeral ligament with inflammatory
50 pt 50 pt 50 pt
changes.

life, definitive treatment strategies have not been established 6-month follow-up; the mean Constant score, from 28.3
and many different management strategies are used. In this initially to 94.8 at first-year follow-up; the mean American
review article, we provide an overview of treatment methods Shoulder and Elbow Surgeons score, from 25.9 initially
for FS and discuss proper treatment strategies for FS. to 98.7 at first-year follow-up. In one randomized clinical
trial of 40 patients performed by Lorbach et al.,17) patients
with idiopathic FS were treated with an oral corticosteroid
CONSERVATIVE TREATMENT treatment regimen (20 patients) or intra-articular injection
Common conservative treatments include oral medica- of corticosteroid (20 patients). In the patients treated with
tion, physical therapy, exercise, steroid injection, and the oral regimen, significant improvements were found
hydrodilatation. These initial conservative managements for pain and functional outcomes at the 4-week follow-up.
may be successful in up to 90% of patients.12) It is impor- However, the patients treated with an intra-articular injec-
tant to note the phase being treated because of differences tion showed superior results in objective shoulder scores,
in symptoms at each phase.5,13,14) In freezing phase (dura- ROM, and patient satisfaction compared with the oral
tion, 10–36 weeks), pain is most prominent. Steroid injec- steroid group.17) Buchbinder et al.18) reported the results
tion provides rapid pain relief, mainly in the short-term of oral prednisolone for the treatment of FS in a random-
period.13,14) In frozen phase (4–12 months), pain gradually ized, double-blinded, placebo-controlled study and found
subsides but restricted ROM is predominant. In this phase, significant improvement in the study group at 3 weeks. As
therapy should focus on increasing ROM, such as mobili- described in the previous studies, oral steroid treatment
zation techniques or distension for which limited evidence seems to provide early benefit both in terms of pain relief
was found.13,14) In the thawing phase (12–42 months), there and functional outcomes; however, long-term benefit has
is minimum pain and progressive improvement in ROM. not yet been established. One systematic review reported
As pain and muscular inhibition result in compensatory on the use of oral steroid in the treatment of FS (five tri-
movements of the scapula, the role of adaptation of scapu- als, 179 patients). In three high-quality trials, oral steroids
lar motion could be important in managing rehabilitation were compared with placebo or observation. No signifi-
in FS.9,13) cant differences were found in pain in the short term and
in pain and ROM in the long term.19)
Medication Calcitonin is a polypeptide hormone secreted from
During the initial painful freezing stages, treatment strat- parafollicular cells of the thyroid. Although the mecha-
egy is directed at pain relief. Although it is traditional nism of action of calcitonin is not fully understood, it
to give patients nonsteroidal anti-inflammatory drugs plays a significant role in managing rheumatoid arthritis,
(NSAIDs), NSAIDs alone have no effect on the natural complex regional pain syndrome, fracture, and metastasis
course of FS.13,15) There are no randomized controlled tri- of bone tumor.20,21) And it is thought to decrease the sys-
als that confirm the effectiveness of NSAIDs in the specific temic inflammatory response and stimulate the release of
condition of FS. endorphins.22) A double-blinded randomized clinical trial
Oral administration of corticosteroid is also used (level of evidence II) of 64 patients with FS compared in-
in the treatment of FS. Canbulat et al.16) reported that oral tranasal calcitonin and placebo for 6 weeks. Physiotherapy
glucocorticoids (0.5 mg/kg/day methylprednisolone) in and NSAIDs were administered equally to both groups.
33 FS patients improved clinical outcomes: the mean vi- At 6 weeks, both groups had significant improvement in
sual analog scale (VAS) score, from 6.3 initially to 0.2 at pain, ROM, and functional outcomes. However, the im-
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provement in the calcitonin group was more notable than Corticosteroid Injection
that in the placebo group. But there are few well-designed Although injection of corticosteroids is an invasive proce-
studies; therefore, further research is needed to evaluate dure and associated with risks such as septic arthritis,17) it
whether a calcitonin has an effect on the treatment of FS. is useful to reduce pain and disability of the patients dur-
ing painful or freezing stages.3,31) There have been numer-
Physiotherapy ous randomized studies that examined the early efficacy of
Physiotherapy is widely adopted as an initial treatment in steroid injection.32-34) In a double-blinded, sham-controlled
many shoulder conditions including FS.23,24) Physiotherapy randomized clinical trial, ultrasonography-guided intra-
should include an exercise program that can restore shoul- articular and rotator interval steroid injections in 122
der motion. The patient should be placed on an exercise patients with FS resulted in a notable decrease in pain at
program with the goal of regaining and maintaining mo- 6 weeks. The result was maintained at 12 weeks, but not
tion. Patients receiving exercise therapy should begin an at 26 weeks. And there was no difference between the
active assisted ROM exercise program as well as gentle group who received intra-articular injection and the group
passive stretching exercises including forward elevation, who received both intra-articular and rotator interval
internal and external rotation, and cross body adduction. injections.35) Ryans et al.36) reported results of a four-way
These exercises should be performed five to six times per randomized controlled trial comparing (1) an injection
day. And it is important to perform multiple 5- to 10-min- of triamcinolone plus physiotherapy, (2) injection alone,
ute sessions per day as the shoulder will become stiff again (3) placebo injection plus physiotherapy, and (4) placebo
in the time between sessions.25) injection alone. At 6 weeks’ follow-up, corticosteroid in-
Good results have been reported with physiotherapy jection groups were significantly improved in terms of
itself or in comparison with other conservative manage- shoulder-related disability, and physiotherapy groups had
ment.24,26,27) Russell et al.26) conducted a blinded, random- improvement in ROM. However, all groups had improved
ized, controlled study comparing the efficacy of three to a similar degree with respect to all outcome measures
treatment regimens: exercise class plus home exercises, at 16 weeks. In 2011, Griesser et al.33) conducted a system-
individual multimodal physiotherapy plus home exer- atic review of existing level I and II evidence studies about
cises, and home exercises alone. They found the exercise intra-articular injection for FS. Eight studies comprising
class group showed significant improvement in Oxford 409 shoulders met their criteria for inclusion. Even though
and Constant scores. The improvement in ROM was the mean modified Coleman methodology score of the in-
significantly greater in the physiotherapy group than the cluded studies was as low as 44, all treatments resulted in
exercise alone groups. They emphasized that compared improved clinical outcome with a trend toward greater im-
with exercise, physiotherapy interventions lead to signifi- provement in 36-Item Short Form Survey (SF-36) scores
cant improvement in anxiety, which is strongly correlated in association with steroid injection as compared with ma-
with symptoms. Griggs et al.24) reported that 90% of the nipulation under anesthesia (MUA).
75 patients treated with use of a specific four-direction There is no clear evidence as to which injection site
shoulder-stretching exercise program obtained satisfac- is most effective. In a study by Oh et al.,37) a glenohumeral
tory results at a mean follow-up of 22 months. Sun et al.27) joint steroid injection (37 shoulders) was not superior to
undertook a systematic review and meta-analysis of ran- a subacromial injection (34 shoulders) for patients with
domized controlled trails to evaluate the effect of steroid primary FS at 6 and 12 weeks, even though the glenohu-
injection and physiotherapy. They concluded that both meral injection led to earlier pain relief compared with the
interventions had similar effect on improving shoulder subacromial injection. For ROM, no statistical differences
function, increasing passive motion, and decreasing pain were found between the groups at any of the follow-up as-
in FS. sessments. Shin and Lee38) randomly divided 191 patients
Many studies have demonstrated physiotherapy into four groups who underwent one of the following
as an adjunctive intervention that provides good results. treatment methods: corticosteroid injection into the sub-
NSAIDs were proven to be more effective when used in acromial space, glenohumeral joint, or glenohumeral joint
combination with physiotherapy as compared to NSAIDs combined with subacromial space, or oral NSAID medi-
alone.28) Similarly, steroid injection used in combination cation. They found that steroid injection provided faster
with physiotherapy resulted in better outcomes compared pain relief, a higher level of patient satisfaction, and earlier
to injection alone.29,30) recovery in shoulder function than medication. But, the
efficacy of a corticosteroid injection was not found to be
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related to the site of injection. Cho et al.39) randomly as- ROM and concluded that HD has only a small, clinically
signed 126 patients with idiopathic FS to intra-articular insignificant effect when treating FS.45)
injection group, subacromial injection group, or combina-
tion (intra-articular plus subacromial) injection group.
Their results revealed that intra-articular injection or com-
SURGICAL PROCEDURE
bination injection was superior to subacromial injection. Despite the self-limited natural history of the disease,
And combination injections showed an additive effect on some patients fail to achieve desired outcomes with non-
internal rotation angle. operative management.9,22,46) Factors that influence the
decision on surgical management include severity and
Hydrodistension duration of symptoms as well as response to conservative
Andren and Lundberg40) first described hydrodistension treatment.3,22)
(HD) in 1965 to treat the adhesive glenohumeral joint by General indications for surgery are persistent pain
expansion of the capsule. Although therapeutic regimens and limited motion despite a minimum 3 to 6 months of
will differ, this technique is the installation of a large vol- nonoperative management including medication, local
ume of saline, steroid, local anesthetic, and contrast agent injections, or physiotherapy.9,46,47) Levine et al.12) reported
into the glenohumeral joint under imaging guidance.41-43) that patients with more severe initial symptoms, younger
Most studies comment on a procedure to achieve capsu- age at the time of onset, and reduction in motion despite
lar rupture but have not investigated this.41,42) There is no 4 months of compliance with therapy are most likely to
evidence to determine whether capsule rupture must be require surgery.
achieved or whether capsular distension is most impor- As with the increase in patients with FS, surgical in-
tant. tervention for FS is common these days. The overall inci-
HD has been reported to provide short-term ben- dence of FS surgery was calculated as 2.67 procedures per
efits regarding pain, ROM, and function in FS.41) Haugh- 10,000 general population per year and as 7.55 for those
ton et al.42) reported results of HD in 76 patients with a aged 40–60 years.48,49) Management of FS amongst doctors
mean follow-up of 3.5 months. The Oxford shoulder score varies substantially and is highly based on personal experi-
improved from a mean of 20.6 preoperatively to a mean of ence and training rather than published evidence.49) Op-
32.7 postoperatively. A Cochrane review in 2008 demon- erative treatment methods include MUA and arthroscopic
strated only silver level evidence to support HD as a treat- or open capsular release. As arthroscopic capsular release
ment modality for short-term improvement of pain, ROM, (ACR) is a reliable treatment option with many advantages
and function.41) over open surgery, the indications of open release have de-
Good long-term outcome was also reported in sev- creased and open release is now rarely performed.
eral studies.43,44) Watson et al.44) demonstrated the efficacy
of HD in 41 patients with a 2-year follow-up. Primary out- Manipulation under Anesthesia
comes included Shoulder Pain and Disability Index and MUA involves passive tearing of the thickened inflamed
Shoulder Disability Index and secondary included ROM. capsule and contracted ligaments (Fig. 2). It is mainly per-
They found significant improvement in all outcomes over formed under general anesthesia; however, recent devel-
the follow-up period, and these benefits associated with opment of ultrasound technology enabled it with brachial
HD and physiotherapy continued to improve or were
maintained in the long term, up to 2 years after this proce-
dure. Clement et al.43) also demonstrated similar results of
arthrographic distension in 53 FS with a mean follow-up
of 14 months. The Oxford shoulder score improved from
a mean of 22.3 at baseline to a mean of 39.2 at final follow-
up and VAS score decreased from a mean initial value of
7.1 to a mean of 3.6. In 2018, Saltychev et al.45) evaluated
the evidence on the effectiveness of HD in treatment of FS
in a meta-analysis. The seven included studies assessed the
essential effect of HD combined with corticosteroid versus A B
corticosteroid alone. They reported that the amount of in-
50 pt 50 pt

jected solution did not have a substantial effect on pain or Fig. 2. (A, B) Capsular tearing after manipulation under anesthesia.
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plexus or cervical nerve root block.50,51) Magnetic reso- the shoulder during two sequential axial movements.63)
nance imaging after MUA shows capsular tears (midsub- The first step of their MUA method is elevation of the arm
stance and humeral avulsion of glenohumeral ligaments), in the plane of the scapula that is stabilized with a very
labral tears, or bone bruises of the humeral head.51) And short lever arm. The second step is bringing the arm that
arthroscopic findings of post-MUA include hemarthrosis, is in full external rotation down by the side without any
tearing of the joint capsule or rotator cuff, superior labrum rotation. In this setting, MUA can be performed without
from anterior to posterior tear lesion, labral tear, middle any rotation torque on the humerus.63)
glenohumeral ligament rupture.52)
Even though the optimal timing of MUA has not Arthroscopic Capsular Release
yet been determined, Vastamaki et al.53) suggested that if Due to complications of MUA and advances in arthroscop-
conservative management failed, the best time for MUA ic techniques, ACR has become the most frequently used
might be between 6 and 9 months from the onset of the surgical intervention that was previously shown to confer
symptom. They believed that too early manipulation (be- lasting long-term improvements in symptoms (Fig. 3).49)
fore 6 months after the onset of symptom) may lead to a ACR also allows for visual confirmation of the diagnosis
recurrence because the disease is still at the inflammation as well as the ability to treat concomitant intra-articular
stage.53) MUA has been used extensively with satisfactory and subacromial disease that may be contributing to the
short- and long-term results. Thomas et al.54) noted that primary cause of the problem.25)
246 patients with an idiopathic FS treated by MUA had Recently, many studies have shown excellent results
good clinical outcomes at a mean of 42 months. Vastamaki both in terms of pain relief and ROM gain with ACR. In
et al.55) evaluated 26 patients after MUA for FS and a sub- a study by Le Lievre and Murrell,64) 49 shoulders treated
stantial increase in ROM and pain relief were found at 7 with an ACR obtained early significant improvements in
years’ follow-up. These authors also showed maintained ROM, pain relief, and function. These improvements were
improvement in ROM, pain, and function at 23 years in a maintained at 7 years.64) Furthermore, even when com-
group of 16 shoulders treated with MUA.55) pared with other procedures such as HD and MUA, ACR
However, the results of MUA, when compared to had good clinical results. Gallacher et al.65) compared the
HD or steroid injection, are equivocal at best.56) Quraishi 6-month follow-up results of HD (20 patients) for FS with
et al.57) performed HD in 20 shoulders with FS and com- ACR (19 patients). They reported that patients random-
pared the results with those of manipulation performed in ized to ACR showed a significantly higher Oxford shoul-
18 shoulders. Most of their patients were treated success- der score at 6 months than the HD group.65)
fully. However, the Constant scores in the HD group were There is a wide variation in the way ACR is carried
significantly better than those in the manipulation group out, ranging from partial release to a full 360º release. Also
over the 6 months of follow-up. Furthermore, 94% of pa- there are various debates in the literature regarding the
tients were very satisfied or satisfied after HD, compared extent of release. Several authors recommended release
with 81% of manipulation group at the final follow-up.57) of the posterior capsule, and it was believed to have ad-
The recurrence rate after MUA varies from 3% to vantages regarding the recovery of internal rotation.66-70)
40%.58-60) Jenkins et al.59) reported that 36% of patients who On the contrary, Chen et al.71) reported that although the
had diabetic FS required a repeat MUA versus 15% for
nondiabetic shoulders. With the repeat MUA, 85% of the
patients were successfully treated.59) Woods and Logana-
than58) performed MUA in 730 patients with FS. A further
MUA was undertaken in 17.8% and patients with type-1
diabetes mellitus were at 38% increased risk of requiring a
further MUA.
Surgeons should be always concerned about the risk
of complications related to MUA, including humeral shaft
fracture, glenoid fracture, rotator cuff tear, dislocation of A B
shoulder, and traction injury to nerve.61,62) Tsvieli et al.63) 50 pt 50 pt

reported that understanding of Codman’s paradox enabled Fig. 3. (A) Intraoperative arthroscopic image showing a release of the
them to minimize the risk of complications during the anterior capsule with an ablation device. (B) The appearance of the
MUA. This paradox leads to an apparent 180º rotation in capsule after radiofrequency ablation.
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ROM (abduction and internal rotation) improvement was

more significant in the addition of posterior release within CONCLUSIONS
the first 3 months after ACR, there was no significant FS, commonly encountered in general orthopedic practice,
improvement in function or internal rotation with the ad- is a condition of pain and stiffness with consequent func-
dition of posterior release at mean of 28 months after sur- tional impairment. Appropriate treatment decisions for
gery. FS require a comprehensive understanding of pathophysi-
Some surgeons prefer MUA followed by ACR, ology, patient’s systemic medical condition, functional
which has also provided satisfactory results. De Carli et demands, severity of symptoms, and response for nonop-
al.72) followed up 23 patients who underwent MUA and erative treatment. The majority will experience resolution
arthroscopic arthrolysis for a minimum of 12 months and when treated conservatively; thus, conservative manage-
compared the results with those of intra-articular steroid ment should be the first option.
injection performed in 21 patients. They found patients of NSAIDs may relieve pain and reduce sleep distur-
MUA followed by arthroscopic surgery accomplished their bance, but they do not have a substantial effect on recov-
goal by the 6-week follow-up, whereas in the injection ery. Oral steroid may provide rapid pain relief and ROM
group, the same result was obtained at 12 weeks. Grant et recovery in the short term. Physiotherapy is so widely ac-
al.73) conducted a systematic review of 22 studies that com- cepted that it should be used in the conservative manage-
pare outcomes between MUA, capsular release, or a com- ment of FS. When patients have the most pain, steroid in-
bination of both. Of the study participants, the median jections can be beneficial in the early period of the disease
age was 52 years and 60% were women. They concluded (particularly, in the first 6 weeks). But longer-term results
that even though the quality of evidence available was low, would show no difference between patients treated with
there was little benefit of ACR instead of or in addition to steroids and control subjects. There is still debate on the
MUA. appropriate steroid injection site. The HD alone appears to
Overall, ACR in FS is a safe procedure with a low provide only a small, clinical benefit, and there is no evi-
complication (nerve injury, chondrolysis, or instability) dence to suggest any superiority to other treatments.
rate; however, caution to axillary nerve injury is needed. Initial conservative management may be success-
To prevent possible injury to the axillary nerve, some au- ful in up to 90% of patients. Patients who are regressing
thors were very cautious about the inferior release.71) In despite appropriate therapy are likely to require surgical
cadaveric dissections, the teres minor branch of axillary intervention. MUA has been used extensively with satis-
nerve was the closest to the 5:30 and 6 o’clock position on factory outcomes. However, surgeons always need to take
the inferior glenoid rim. At this position, the average dis- caution to avoid iatrogenic complications and should ex-
tance between the axillary nerve and the glenoid rim was plain the possibility of recurrence in patients with diabetes.
12.4 mm (10 to 25 mm) and the nerve lay at an average of Although the extent of additional capsule that should be
2.5 mm from the inferior glenohumeral ligament. The ab- released remains controversial, ACR is a reliable treatment
duction-neutral position resulted in the greatest distance method, with a low complication rate, for restoring func-
between the inferior glenoid and the axillary nerve.74,75) tion and reducing pain in patients with FS. Patients should
begin progressive ROM exercises as soon as possible un-
Rehabilitation der the supervision of a trained therapist.
Postoperative rehabilitation is another very important
point in the surgical treatment. If possible, rehabilitation
should be started as soon as possible in order to maintain CONFLICT OF INTEREST
movement gain achieved intraoperatively. Some authors No potential conflict of interest relevant to this article was
recommended the use of continuous interscalene catheter reported.
for anesthetic infusion in the early postoperative period to
improve pain relief and patient satisfaction.76) An arm sling
is only used for comfort for a few days after surgery and
must not be continued by 1 week. Patients are encouraged
not to sleep in the arm sling. A home stretching program
is taught and should be done three times per day.22,47)
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