Makindo Medical Notes

🦴 About

• Frozen shoulder (Adhesive capsulitis) = adhesion of the glenohumeral joint capsule to the humeral head → pain & stiffness.
• Typically affects women aged 40–60 years.
• ~1 million cases per year in the UK.
• Often self-limiting but recovery may take 2–4 years.

⚠️ Aetiology / Risk Factors

• Idiopathic (primary) – associated with diabetes, thyroid disease, autoimmune conditions.
• Secondary – after trauma, surgery, mastectomy, fracture, stroke (hemiparetic shoulder), MI, shingles.
• Diabetes = ~3× increased risk (up to 20% lifetime prevalence in diabetics).

🩺 Clinical Features

• Deep, dull, poorly localised shoulder pain (often worse at night).
• Restriction in all movements – especially external rotation and flexion.
• Stiffness gradually worsens → then plateaus → then improves (“freezing, frozen, thawing” phases).
• Natural history may last several years; some residual stiffness may persist.

🔎 Differentials

• Polymyalgia rheumatica, rheumatoid arthritis, SLE.
• Osteoarthritis of glenohumeral or acromioclavicular joint.
• Rotator cuff tear, impingement syndrome.
• Fractures around shoulder.

📊 Classification

• Primary (idiopathic): Often autoimmune/diabetic/thyroid link; sometimes after minor trauma (~15%).
• Secondary: After identifiable insult – stroke, MI, mastectomy, fracture, surgery, or infection.

🧪 Investigations

• Clinical diagnosis is key.
• Plain X-rays: usually normal, but exclude fractures/arthritis.
• MRI: may show thickened joint capsule or coracohumeral ligament.

💊 Management

• 🔹 Preventive: Good shoulder care post-stroke or mastectomy.
• 🔹 Conservative: Analgesia (NSAIDs, paracetamol), physiotherapy, daily stretching exercises.
• 🔹 Injections: Intra-articular corticosteroid injections can reduce pain & improve ROM in early stages.
• 🔹 Procedural:
  • Manipulation under anaesthesia (MUA) if severe persistent restriction.
  • Arthroscopic capsular release if resistant to other measures.
• Natural history: Often self-limiting, but recovery can take 18–36 months.

📚 References

• Oxford University Hospitals – Frozen Shoulder Patient Info

🌟 Teaching Pearl: Frozen shoulder is the only common shoulder condition where active and passive movement are equally restricted, with external rotation most affected.

Case examples

• 🧍‍♀️ Case 1 – Age 47: Office worker developed gradual onset of shoulder pain and stiffness over six months without preceding trauma. Night pain disturbed sleep, and both active and passive movements were restricted. Diagnosis: Primary (idiopathic) adhesive capsulitis. Management: Oral NSAIDs, image-guided intra-articular corticosteroid injection, and physiotherapy focusing on gentle range-of-motion exercises. Teaching point: Frozen shoulder progresses through three stages — painful (“freezing”), stiff (“frozen”), and recovery (“thawing”) — often resolving over 1–3 years.
• 💉 Case 2 – Age 58: Type 2 diabetic with poor glycaemic control developed progressive shoulder stiffness following minor strain. Pain limited dressing and overhead movement. Diagnosis: Secondary adhesive capsulitis associated with diabetes. Management: Glycaemic optimisation, physiotherapy, and ultrasound-guided hydrodilatation. Teaching point: Diabetic patients have higher risk, bilateral involvement, and slower recovery due to glycosylation of the joint capsule.
• 🏥 Case 3 – Age 52: Patient immobilised in a sling for six weeks after distal radius fracture began to notice shoulder stiffness and pain. Examination confirmed restricted glenohumeral movement in all directions. Diagnosis: Post-traumatic adhesive capsulitis. Management: Early physiotherapy, capsular stretching, and analgesia; manipulation under anaesthesia considered if poor progress. Teaching point: Prolonged immobilisation predisposes to capsular fibrosis — early mobilisation after injury or surgery is vital for prevention.