In patients with frozen shoulder, the movement of the shoulder is severely restricted and there is loss of both active and passive range of motion [7]. Presentation is the same for both idiopathic frozen shoulder and frozen shoulder as a result of injury. Apart from restriction of movement, vertebral pressure, headache and insomnia are among common presentations.

Frozen shoulder is majorly a clinical diagnosis but imaging can also be used to exclude other causes of shoulder pain and depict findings that increase the confidence in clinical diagnosis. Arthrography is usually seen as the standard for imaging diagnosis [8].

Laboratory studies are rarely required in the evaluation of adhesive capsulitis. However, if a predisposing medical condition that may be contributing to adhesive capsulitis is suspected, the patient may be subjected to the following tests:

• CBC
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein
• Serum blood sugar
• Thyroid stimulating hormone (TSH)
• Free thyroxine index (FTI)

In managing this disorder, the focus is on restoring joint movement and reducing shoulder pain. This may involve medications, physical therapy and surgical intervention [9]. The treatment may continue for months but there is no clear evidence on the best approach to take for treatment. Surgical evaluation of other complications such as the rotator cuff tear or subracomial bursitis may be needed.

Medications used most of the time are NSAIDs but corticosteroids are used in other cases either locally via injection or systemically. Manual therapists such as chiropractors and physiotherapists may also administer extensive stretches each day and massage therapy. The Spencer technique may also be used to treat the shoulder [10].

As discussed in the pathophysiology, most patients regain function range of motion but 10-15% suffers from remaining handicap which may be either pain or restricted motion [6]. Ten years down the line however, improvement may be seen with the handicap. Recurrence of primary frozen shoulder is very rare.

There is a lack of clear evidence linking frozen shoulder to a specific etiology but there are various triggers that may predispose patients to this problem [2]. Some etiologic agents that have been identified in cases of adhesive capsulitis include the following:

• Various shoulder ailments
• Diabetes
• Inflammatory disease
• Surgery
• Trauma

Additionally, an autoimmune theory has been postulated with elevated levels of C-reactive protein as well as an increase incidence of HLA-B27 histocompatibility antigen often seen in patients with this condition.

Primary adhesive capsulitis is often considered to be a self-limiting disease that will last for 18-24 months but will heal in most cases, not leaving any residual handicap behind [4]. The condition often develops in three periods with duration of six months in each.

• The first period is freezing
• The second period is frozen
• The third period is thawing

The freezing stage shows an insidious onset where pain is the major clinical picture. Most of the time, subacromial impingement is suspected due to the involvement of the subacromial bursa. By the end of this period, it becomes difficult to carry out a range of motion, making diagnosis very simple.

During the frozen period, there is a reduction of pain but the restricted mobility remains.

The thawing stage shows successive reestablishment of normal or near normal range of motion.

In frozen shoulder, there is a lack of synovial fluid which makes it possible for ball and socket joints to move with its lubricating action between the humerus and the shoulder blade socket [5]. The shoulder capsule also thickens, swells, and tightens due to bands of scar tissue (adhesions) which have formed inside the capsule. As a result of this, there is far less room in the joint for the humerus and this makes movement of the shoulder not only stiff but also painful. The main difference between stiff shoulder and adhesive capsulitis is this restricted space between the capsule and the ball of the humerus.

One of the most common causes of frozen shoulder is the immobility that often results during recovery from a shoulder injury, broken arm or following a stroke. People who have had injuries that make it difficult for them to move their shoulders, should talk to their doctors on what exercises will be best for them to maintain a range of motion in their shoulder joint and avoid a frozen shoulder.

Frozen shoulder or adhesive capsulitis is a disorder that is both painful and of an unclear cause where the shoulder capsule becomes stiff and inflamed [1]. The shoulder capsule is the connective tissue surrounding the glenohumeral joint of the shoulder and its inflammation brings about chronic pain. The pain is often constant, worse at night and with cold weather. Certain movements can also provoke episodes of tremendous pain and cramping. The condition is believed to be caused by injury or trauma to the area and may have an autoimmune component.

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