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What is a Frozen Shoulder?
Various triggers have been associated with adhesive capsulitis. The condition often has no clear cause, or is idiopathic, but has been associated with systemic conditions such as diabetes mellitus and hypothyroidism [Ramirez, 2019; Navarro-Ledesma et al, 2024].
Risk factors for adhesive capsulitis are multifactorial, involving metabolic, genetic, and lifestyle components:
Diabetes Mellitus: Multiple studies have consistently identified diabetes as a significant risk factor for adhesive capsulitis. Patients with diabetes have a higher prevalence of this condition compared to the general population. Approximately 10-20% of patients with diabetes develop adhesive capsulitis [Cao et al, 2022; Kingston et al, 2018; Abudula et al, 2024].
Female Gender: Females are more likely to develop adhesive capsulitis than males. This has been supported by various studies and is considered an independent risk factor. Females are 1.5 to 2 times more likely to develop adhesive capsulitis than males [Wang et al, 2013; Kingston et al, 2018; Abudula et al, 2024].
Age: The condition is more common in individuals aged 40-70 years, with a peak incidence in the 50-60 year age group [Cao et al, 2022; Kingston et al, 2018].
Obesity: Higher body mass index (BMI) is associated with an increased risk of developing adhesive capsulitis with 27-30% of patients with adhesive capsulitis are classified as obese [Cao et al, 2022; Kingston et al, 2018].
Thyroid Disorders: Hypothyroidism and hyperthyroidism have been linked to an increased risk of adhesive capsulitis. Hypothyroidism is present in approximately 10-20% of patients with adhesive capsulitis [Wang et al, 2013; Kulm et al, 2022].
Previous Shoulder Injuries or Surgeries:
History of shoulder trauma, surgeries, or conditions such as rotator
cuff disease, biceps tendinitis, and calcific tendinitis are associated
with a higher risk. Frozen shoulder was identified in 11% of the patients after shoulder surgery and was more common in females (15%) than in males (8%) [Koorevaar et al, 2011].
Genetic Factors:
Genetic predisposition has been suggested, with specific loci
identified that may increase susceptibility to adhesive capsulitis [Kulm et al, 2022].
Other Comorbidities: Conditions such as hyperlipidemia, cervical spondylosis, and cardiovascular diseases have also been associated with an increased risk [Wang et al, 2013; Sun et al, 2024].
Conservative Treatment
Early intervention strategies for patients at high risk of developing adhesive capsulitis (frozen shoulder) include:
Intra-articular corticosteroid injections: These are effective in reducing pain and improving shoulder function, particularly in the early stages of the condition. The American Academy of Orthopaedic Surgeons highlights the role of early corticosteroid injections in shortening the duration of symptoms [Redler & Dennis, 2019].
Physical therapy: This includes joint mobilization and stretching exercises, which are crucial for maintaining range of motion and preventing stiffness. Combining physical therapy with corticosteroid injections may provide greater improvement than physical therapy alone [Ramirez, 2019].
In many cases, adhesive capsulitis resolves on its own. In other people, conservative treatments don’t work and patients consider surgery (manipulation under anesthesia or shoulder arthroscopic surgery).
High-volume distention of the shoulder joint capsule has been shown to provide pain relief and immediate improvement in range of motion. This procedure has shown superior results when compared to other conservative treatments, and in a recent study by Gallacher et al. (2018) showed similar results to surgery. In this study, high-volume distention showed similar improvement in range of motion and pain when compared to surgery (arthroscopic capsular release).
High-volume distention is an office-based procedure performed with local anesthesia and involves injecting fluid into the intra-articular space to expand the stiff joint capsule and eliminate adhesion or scar tissue limiting the range of motion and causing pain. High-volume dilation should be considered before surgery.
In a recent study by Dr. Lee et al, 15 patients with chronic adhesive capsulitis were treated with an intra-articular PRP injection and followed for 6 months after the injection. At the 6-month follow up the patients that had received the PRP injection had a significant improvement in pain and range of motion compared to a matched control group that only received a steroid injection. Conclusion: PRP demonstrated a significant improvement in pain and function in patients with a frozen shoulder compared to steroid injections.
PRP is a natural reservoir of cytokines and growth factors and has been shown to inhibit the release of proinflammatory molecules in joints.
Manipulation Under Anesthesia
References