Ombro Congelado Folheto

O que você está sentindo

O ombro congelado geralmente começa com uma dor profunda e surda que se intensifica ao longo de semanas, em vez de aparecer subitamente. Para a maioria das pessoas, a dor é a parte mais grave no início, sendo frequentemente mais intensa à noite. Deitar-se do lado afetado torna-se impossível, e o sono fragmentado é uma das partes mais exaustivas de toda a condição.

Em seguida, o ombro começa a travar. Você estende o braço para cinto de segurança, para uma prateleira alta ou para um bolso, e o braço simplesmente para. O que diferencia o ombro congelado da maioria dos problemas de ombro é que a rigidez não é apenas uma proteção contra a dor — o ombro realmente não se move, mesmo que outra pessoa mova seu braço para você. Perder a capacidade de girar a mão para fora, como ao abrir uma porta ou colocar o braço em uma manga, é o sinal mais característico de todos.

A maioria das pessoas tem entre 40 e 60 anos. Algumas lembram de um leve impacto antes; muitas não têm nenhuma explicação. É mais comum se você tiver diabetes ou uma condição da tireoide, e se você já teve em um ombro, há uma chance modesta de o outro seguir mais tarde.

O que está realmente acontecendo

A sua articulação do ombro está contida dentro de uma capa de tecido resistente chamada cápsula. Normalmente, essa capa é frouxa e elástica, o que permite que o ombro se mova mais do que qualquer outra articulação do corpo. No ombro congelado, a cápsula torna-se inflamada e, em seguida, espessa e contrai, fazendo com que a capa encolha. O espaço no interior da articulação pode acabar sendo menos da metade do seu tamanho normal.

Apesar do nome mais antigo "capsulite adesiva", nada está realmente colado no interior da articulação. Não há aderências semelhantes a cola. O tecido enrijeceu, o que é um problema genuinamente diferente, e é por isso que alguns cirurgiões argumentam que a condição deveria ser simplesmente chamada de contratura — um enrijecimento — do ombro.

A razão pela qual começa ainda não é bem compreendida, e é honesto dizer isso. Há boas evidências de que não é puramente um problema local no ombro. Estudos de risco hereditário mostram que o diabetes tipo 1 causa genuinamente o ombro congelado em vez de apenas estar associado a ele, e que a ligação ocorre por meio da glicose no sangue em vez de por meio do peso ou da carga mecânica. As alterações teciduais parecem strikingly semelhantes à doença de Dupuytren na mão, é por isso que as duas frequentemente aparecem na mesma pessoa.

Ser honesto sobre o tempo necessário

É muito provável que você leia que o ombro congelado é autolimitado e se resolve completamente em cerca de dezoito meses a dois anos. Queremos ser diretos com você: esse conforto é mais confiante do que as evidências sustentam.

A ideia de que a condição passa de forma ordenada por três fases — congelamento, ombro congelado e descongelamento — provém de um pequeno estudo publicado em 1975, no qual os pacientes mantinham os braços em suporte (mucrilas) por até nove meses. Não surpreendentemente, os ombros tratados dessa maneira tornaram-se rígidos e depois relaxaram novamente quando o movimento foi permitido. Quando os pesquisadores revisaram todos os estudos disponíveis, não conseguiram encontrar boas evidências de que os ombros não tratados passem de forma confiável por essas fases e terminem com normalidade. De fato, nenhum estudo já demonstrou que as pessoas recuperem uma amplitude de movimento medida e genuinamente normal sem tratamento.

O que as evidências mostram é mais útil, e é o seguinte: a maior parte da melhora que você vai obter tende a ocorrer no início, e então o progresso desacelera e se estabiliza. Esse platô pode ser permanente. Dependendo do estudo que você ler, entre um terço e metade das pessoas ainda apresentam algum desconforto ou rigidez vários anos depois, embora, para a maioria delas, seja leve e não impeça que façam o que desejam.

Nada disso significa que você não vai melhorar. A maioria das pessoas melhora significativamente. Significa apenas que "apenas espere, isso se resolverá sozinho" não é um conselho neutro, e que há um argumento razoável para tratar a dor ativamente, em vez de simplesmente suportá-la.

O que podemos fazer a respeito

No Mater Private Hospital Rockhampton, o Dr. Kieran Hirpara explicará as opções com base no que mais o incomoda — a dor ou a rigidez — em vez de tentar encaixá-lo em um estágio numerado.

Uma injeção de corticosteroides na articulação é o tratamento com o maior respaldo científico para a fase dolorosa. Em um corpo de pesquisa muito amplo, é o único tratamento que produz consistentemente uma diferença na dor e na função que os pacientes realmente percebem, e atua nas primeiras semanas. Sua limitação honesta é que a vantagem desaparece em torno de quatro a seis meses. Ela proporciona conforto, sono e a capacidade de trabalhar com o ombro — não cura a rigidez.

Exercícios e fisioterapia valem a pena, com expectativas realistas. Um programa simples de exercícios em casa tem valor mensurável. O que pode surpreender você é que a intensidade do esforço não parece importar: estudos que compararam alongamentos firmes até o limite da amplitude de movimento com movimentos suaves e sem dor não encontraram diferença nos resultados aos seis e doze meses — e, tranquilizadoramente, não há evidências de que forçar mais causa danos. Portanto, atue dentro do que você consegue tolerar. Lutar contra uma dor severa não demonstrou acelerar nada.

Hidrodilatação, na qual o fluido é injetado para estirar a cápsula por dentro, é amplamente utilizada e de baixo risco. A pesquisa sobre ela é genuinamente mista: uma grande revisão encontrou que ajudou um pouco na dor, mas não no movimento, enquanto outra encontrou o inverso. É uma opção razoável, mas não a superestimaremos.

Manipulação sob anestesia significa mover o ombro por toda a sua amplitude de movimento enquanto você está dormindo, para estirar a cápsula rígida. No maior ensaio comparando os principais tratamentos, esta saiu como a opção de melhor custo-benefício geral.

Liberação capsular artroscópica envolve dividir cirurgicamente a cápsula rígida sob visão direta, em vez de estirá-la até que se rompa. Sua principal vantagem é que tende a ser a mais duradoura: nas séries cirúrgicas publicadas, a rigidez recorrente após uma liberação é incomum, enquanto após uma manipulação, uma proporção significativa dos ombros torna-se rígida novamente e necessita de um segundo procedimento. No grande ensaio do Reino Unido, as pessoas que tiveram uma liberação foram as menos propensas dos três grupos a precisar de qualquer tratamento adicional. Por ser uma operação, carrega um pouco mais de risco do que as alternativas e custa mais, e você deve esperar sentir-se mais dolorido nas primeiras semanas do que alguém que fez uma manipulação — essa diferença inicial se equaliza em torno de seis meses.

Vale saber: nesse ensaio, as três abordagens terminaram com diferenças de poucos pontos entre si em um ano. Isso é genuinamente uma boa notícia, porque significa que a decisão pode ser tomada com base no que se adapta a você, às suas outras condições de saúde e às suas circunstâncias, em vez de uma opção ser claramente melhor.

Como o Dr. Hirpara geralmente sequencia isso. Você não será instruído a suportar por um número fixo de meses antes que qualquer coisa possa ser oferecida. Na prática, ele geralmente sugerirá uma injeção de corticosteroides primeiro, porque, para muitas pessoas, isso reduz a dor o suficiente para retomar a vida enquanto o ombro se estabiliza. Se a injeção não fornecer alívio adequado, ele está disposto a oferecer uma liberação capsular a partir desse ponto — ele não exige que você tenha sofrido por nove ou doze meses primeiro. Dado quão instável se mostra a tranquilização de que "sempre resolve por conta própria", não há muito sentido em passar um ano com dor para descobrir para qual lado a sua irá.

O que esperar

Se receber uma injeção, espere que a dor diminua ao longo da primeira ou segunda semana. Aproveite esse período para manter o ombro em movimento.

Se realizar uma manipulação ou uma liberação capsular, a maior parte da amplitude de movimento que irá recuperar regressa rapidamente — geralmente nas primeiras quatro a seis semanas — e, geralmente, há pouca alteração adicional após cerca de três meses. Começar a mover-se cedo é importante, e a fisioterapia normalmente inicia-se um ou dois dias após o procedimento. A maioria das pessoas regressa a trabalhos de tipo escritório entre uma e três semanas.

Se tem diabetes, é razoável esperar uma recuperação mais lenta e ligeiramente menos completa do que a média, e vale a pena saber que uma injeção de esteroides pode alterar os seus níveis de açúcar no sangue durante alguns dias. Informe-nos se o seu controlo glicémico é difícil, pois isso altera as nossas recomendações.

A recuperação mede-se em meses, não em semanas, independentemente do caminho escolhido. A coisa mais útil que pode fazer é continuar a utilizar o braço dentro de limites confortáveis e proteger o seu sono.

Quando procurar ajuda médica

Consulte o seu médico de família se a dor no ombro o acordar à noite ou não melhorar após algumas semanas de repouso, e pergunte especificamente sobre ombro congelado se o ombro estiver a tornar-se genuinamente difícil de mover, em vez de apenas doloroso.

Solicite uma avaliação especializada mais cedo se não conseguir rodar a mão para fora, se tiver diabetes, se o ombro estiver a afetar o seu trabalho ou a capacidade de conduzir, ou se a dor for suficientemente grave para impedir que durma. Não há vantagem em esperar muito tempo antes de avaliar a dor.

Procure atendimento médico imediato se o ombro ficar quente, vermelho e inchado, se se sentir mal ou com febre, se houver fraqueza significativa ou dormência no braço, ou se a dor começou após uma queda ou lesão. Essas características afastam o diagnóstico de ombro congelado e indicam algo que necessita de avaliação mais urgente.

Em profundidade

Esta secção vai além do necessário para as suas próprias decisões de tratamento. Está aqui porque a capsulite adesiva é uma das condições em que o que é dito aos pacientes e o que a investigação realmente mostra se afastaram, e algumas pessoas preferem ver o raciocínio em vez de serem solicitadas a confiar cegamente.

O que está realmente a falhar na articulação

A cápsula é uma bainha de colagénio à volta da articulação. No ombro congelado, torna-se inflamada e depois fibrosa — células chamadas fibroblastos multiplicam-se e depositam novo colagénio denso, e algumas delas convertem-se em miofibroblastos, que podem contrair-se ativamente. Essa é a diferença chave em relação à cicatrização comum: o tecido não apenas espessa, como também se contrai. O volume articular pode diminuir de 10–15 mL, valor normal, para 3–4 mL.

O mesmo comportamento celular ocorre na doença de Dupuytren na mão, razão pela qual as duas condições surgem nas mesmas pessoas, e por que razão um cirurgião do ombro defendeu que a condição deveria ser simplesmente renomeada contratura do ombro em vez de "capsulite" [1]. Apesar do nome antigo "capsulite adesiva", os cirurgiões que observam o interior da articulação não encontram qualquer adesão.

Por que a história dos "três estágios" está em terreno mais instável do que parece

Você lerá em todos os lugares que o ombro congelado passa pelas fases de congelamento, congelado e descongelamento. Esse modelo foi proposto em 1975. Quando os pesquisadores voltaram atrás para rastrear sua origem, descobriram que o autor havia confundido as referências de dois artigos anteriores diferentes e, mais importante, que seus pacientes mantinham os braços imobilizados em ataduras por até nove meses. Um ombro imobilizado por tanto tempo torna-se rígido e solta-se quando você o deixa se mover. Os "estágios" podem descrever parcialmente o tratamento, em vez da doença.

Uma revisão sistemática que se propôs a testar o modelo não conseguiu encontrar nenhuma evidência para ele e encontrou o oposto do que ele prevê: a maior parte da melhora ocorre cedo e depois desacelera, em vez de aumentar para um descongelamento tardio [2]. Além disso, os clínicos não conseguem concordar de forma confiável em qual estágio determinado ombro se encontra — as pessoas que escreveram a definição padrão admitiram em publicação que os dados para confirmá-la "não estão disponíveis".

A estatística de recuperação e por que ela tem duas respostas muito diferentes

A figura frequentemente citada é que 94% das pessoas se recuperam sem tratamento. Isso provém de um estudo real, mas conta apenas os pacientes que não receberam tratamento e retornaram para acompanhamento. A maioria do grupo original optou pelo tratamento ou abandonou o estudo. Contando todos, os mesmos dados indicam aproximadamente 26% [3]. "Recuperado" também significava estar dentro de 10 graus do outro ombro — e, em alguns desses pacientes, o outro ombro também estava congelado.

O maior acompanhamento a longo prazo encontrou 41% ainda com sintomas, em média, quatro anos depois, e — o aspecto importante a saber — que a melhora para cessa após cerca de três anos, em vez de continuar indefinidamente [4].

É uma condição sistêmica, não apenas uma condição do ombro

Um grande estudo genético identificou cinco regiões do DNA associadas ao ombro congelado e, utilizando uma técnica que pode separar causa de coincidência, demonstrou que o diabetes mellitus tipo 1 realmente o causa, em vez de meramente acompanhá-lo. O sobrepeso não o causava — uma vez ajustado para o diabetes, a associação com o peso desapareceu. Isso aponta para a glicemia, e não para a carga mecânica, como o fator determinante [5].

O que a evidência da fisioterapia realmente diz

Esta é a parte mais importante de se saber se você está a receber ou a prestar fisioterapia. Uma revisão Cochrane agrupou 32 ensaios clínicos e 1.836 pessoas [6]. Três conclusões destacam-se.

Em comparação com uma injeção de corticosteroides, a fisioterapia manual tem piores resultados no início. No ensaio clínico direto, seis semanas de mobilização passiva e exercício supervisionado produziram 26 pontos menos de melhoria na dor e 25 pontos menos de melhoria na função às sete semanas do que uma única injeção. Avaliado pela proporção de pessoas que se sentiram muito melhor ou recuperadas, foi de 46% para a fisioterapia contra 77% para a injeção — aproximadamente uma pessoa extra beneficiada para cada quatro injetadas. Aos seis a doze meses, a diferença fechou-se e a diferença deixou de ser relevante.

A intensidade do esforço, a frequência e a técnica utilizada parecem não importar. Um ensaio clínico com 100 pacientes comparou a mobilização firme no final do arco de movimento com a mobilização suave sem dor e não encontrou diferenças significativas em nenhum dos dezassete resultados aos seis ou doze meses — dor, dor noturna, função, todos os planos de movimento, qualidade de vida. Um ensaio clínico com 120 pacientes que variou a frequência da mobilização no final do arco de movimento (mais de duas vezes por semana, semanalmente, menos de uma vez por semana) encontrou diferenças na abdução de menos de oito graus, todas estatisticamente indistinguíveis de zero. As comparações diretas de técnica — deslize anterior versus posterior, PNF versus exercício convencional, halteres versus mãos nuas — foram quase todas não significativas. De forma reconfortante, também não houve sinais de que trabalhar no final do arco de movimento cause danos.

A maior lacuna estrutural: nenhum ensaio clínico jamais comparou a terapia manual mais exercício contra nenhum tratamento. Portanto, embora possamos afirmar que a fisioterapia não é claramente superior a uma injeção e que os detalhes da sua aplicação não parecem alterar muito os resultados, ninguém demonstrou realmente quanto da melhoria teria ocorrido de qualquer forma.

Duas ressalvas úteis. O único ensaio clínico genuinamente de alta qualidade na revisão analisou a fisioterapia após uma distensão articular e não encontrou diferença na dor, função ou qualidade de vida — mas melhorou a proporção de pessoas que se avaliaram como recuperadas e acrescentou cerca de 13 graus de abdução às seis semanas, o qual desapareceu aos seis meses. E no grande ensaio clínico do Reino Unido, o braço da fisioterapia foi descrito como incluindo alongamento manual no intervalo rígido, mas os seus próprios registos mostram que a mobilização manual foi utilizada apenas em 11–27% dos pacientes e o alongamento supervisionado num único caso. O que foi realmente aplicado — e teve desempenho tão bom quanto a cirurgia ao fim de um ano — foi educação, uma injeção, movimento suave supervisionado e um programa em casa.

Quanto tempo até sentir melhora, e o tipo de liberação importa

Cronograma. Após a liberação, a mediana dos pacientes atinge o limiar de "esta é uma melhora real" em aproximadamente um mês, e o limiar de "meu ombro é aceitável para mim" em aproximadamente quatro meses [14]. O tempo de afastamento do trabalho tem uma mediana de oito semanas, embora haja grande dispersão — um quarto retorna em quatro semanas, três quartos em treze [15].

A manipulação recupera a mobilidade mais rapidamente. Essa é a compensação honesta em relação à vantagem de durabilidade mencionada acima: a manipulação restaura a amplitude de movimento mais cedo, e a liberação não realmente alcança esse patamar até cerca de seis meses, após os quais as duas técnicas são indistinguíveis em todas as medidas agregadas. Uma pequena comparação até encontrou que a manipulação isolada resultou na melhor rotação externa [16].

Quanto da cápsula dividir é uma questão genuína, e a resposta é "menos do que você poderia pensar". Uma revisão que agrupou 18 estudos, 629 pacientes e 811 ombros comparou três técnicas: liberar apenas a parte frontal e a inferior da cápsula, adicionar a parte posterior, ou fazer a volta completa. Sua conclusão foi de que liberações menos extensas proporcionaram melhores escores de função e dor, que adicionar uma liberação posterior proporciona rotação interna precoce que não se mantém (embora proporcione um ganho duradouro de flexão), e que uma liberação completa de 360 graus "pode não fornecer nenhum benefício adicional". As taxas de complicações não diferiram entre os três grupos [17]. Dois ensaios randomizados da extensão posterior encontraram o mesmo padrão — recuperação inicial mais rápida, sem diferença aos seis meses. Portanto, uma cirurgia maior não é automaticamente uma melhor.

Fazer os dois juntos não é a resposta. Na única comparação tripartite, adicionar uma manipulação a uma liberação produziu a maior taxa de perda de rotação externa — 18%, contra 7% para a manipulação isolada e 2% para a liberação isolada [16].

O que a maior ensaio de tratamento realmente descobriu

Um ensaio no Reino Unido randomizou pouco mais de 500 pessoas para fisioterapia estruturada com injeção, manipulação sob anestesia ou cirurgia minimamente invasiva. Aos doze meses, as três abordagens obtiveram resultados dentro de alguns pontos uns dos outros — menos do que a diferença que um paciente notaria [7]. Esta é uma notícia genuinamente útil: significa que a escolha pode ser feita com base no que é mais adequado para si e para as suas circunstâncias, em vez de uma opção ser claramente superior.

Onde as três abordagens diferem é na frequência com que as pessoas necessitam de outro tratamento posteriormente. Nesse ensaio, foi necessário tratamento adicional em 4% dos casos após a liberação, 7% após a manipulação e 15% após a fisioterapia [7]. A manipulação apresentou o melhor custo por unidade de benefício; a liberação foi a mais dispendiosa e gerou a maioria das complicações graves do ensaio, embora estas fossem raras em termos absolutos.

Manipulação ou liberação — a questão da recorrência

É aqui que as duas operações realmente se separam, e é a razão pela qual um cirurgião pode orientá-lo em direção a uma liberação, mesmo que as pontuações de desfecho principais pareçam iguais.

Uma manipulação estira a cápsula até que ela se rompa, e o rompimento nem sempre ocorre no local desejado. Na maior série de casos — 792 ombros acompanhados por 17 anos —, foi necessária uma segunda manipulação em 17,8%, e em pessoas com diabetes tipo 1, esse número subiu para 37,9% [9]. O acompanhamento mais longo, com média de 13 anos, revelou que 19,2% precisaram de uma manipulação repetida e 31,3% descreveram uma recorrência em algum momento [10]. Dois fatores atenuam isso: quase todas as recorrências ocorrem no primeiro ano (após cinco anos, a taxa é inferior a 2%), e uma manipulação repetida funciona tão bem quanto a primeira [9][10].

Uma liberação divide a cápsula deliberadamente, sob visão direta. A reintervenção é marcadamente menos comum: uma série acompanhada por uma média de cinco anos não registrou reintervenções em 32 pacientes, com uma única recorrência em alguém que não concluiu sua reabilitação [11]. A meta-análise que agrupou oito estudos e 768 pacientes não encontrou diferença significativa entre as duas operações para dor, função ou amplitude de movimento, mas observou que o grupo da manipulação necessitou de mais injeções adicionais, concluindo que, em um acompanhamento mais longo, "o grupo da MUA pode experimentar mais recorrências" [8].

Duas ressalvas honestas. Primeiro, os grandes estudos sobre manipulação e recorrência provêm em grande parte da prática de um único cirurgião, portanto, não são confirmações independentes uns dos outros. Segundo, a liberação também não é uma restauração completa: uma série que comparou os resultados com o ombro oposto saudável do próprio paciente mostrou que, dois a seis anos depois, os pacientes apresentavam cerca de 77–79% da função do lado bom [12], e em uma coorte que excluiu diabéticos, embora quase todos tenham melhorado de forma significativa, 11–22% ainda não consideravam seu ombro aceitável aos seis meses [13].

Portanto, o resumo honesto é este: para tornar o ombro móvel e confortável, os dois métodos são aproximadamente equivalentes, e a manipulação é o caminho mais barato. Para manter esse resultado, as evidências favorecem a liberação. Essa diferença é mais relevante se você tiver diabetes, se o ombro estiver muito rígido ou se já tiver passado por uma manipulação que não teve duração suficiente.

Referências

[1] Bunker T. Hora de um novo nome para o ombro congelado — contratura do ombro. Shoulder Elbow. 2009;1(1):4-9. https://doi.org/10.1111/j.1758-5740.2009.00007.x [2] Wong CK, Levine WN, Deo K, Kesting RS, Mercer EA, Schram GA, et al. História natural do ombro congelado: fato ou ficção? Uma revisão sistemática. Physiotherapy. 2017;103(1):40-7. https://doi.org/10.1016/j.physio.2016.05.009 [3] Vastamäki H, Kettunen J, Vastamäki M. A história natural do ombro congelado idiopático: um estudo de seguimento de 2 a 27 anos. Clin Orthop Relat Res. 2012;470(4):1133-43. https://doi.org/10.1007/s11999-011-2176-4 [4] Hand C, Clipsham K, Rees JL, Carr AJ. Desfecho a longo prazo do ombro congelado. J Shoulder Elbow Surg. 2008;17(2):231-6. https://doi.org/10.1016/j.jse.2007.05.009 [5] Green HD, Jones A, Evans JP, Wood AR, Beaumont RN, Tyrrell J, et al. Um estudo de associação genômica ampla identifica 5 loci associados ao ombro congelado e implica o diabetes como um fator de risco causal. PLoS Genet. 2021;17(6):e1009577. https://doi.org/10.1371/journal.pgen.1009577 [6] Page MJ, Green S, Kramer S, Johnston RV, McBain B, Chau M, et al. Terapia manual e exercício para capsulite adesiva (ombro congelado). Cochrane Database Syst Rev. 2014;2014(8):CD011275. https://doi.org/10.1002/14651858.CD011275 [7] Brealey S, Northgraves M, Kottam L, Keding A, Corbacho B, Goodchild L, et al. Tratamentos cirúrgicos comparados com fisioterapia estruturada precoce em cuidados secundários para adultos com ombro congelado primário: o ensaio clínico randomizado de três braços UK FROST. Health Technol Assess. 2020;24(71):1-162. https://doi.org/10.3310/hta24710 [8] Zhao Y, Yang T, Feng C, Li L, Pang L, Zhao S. Liberação capsular artroscópica versus manipulação sob anestesia para ombro congelado refratário: uma revisão sistemática com meta-análise. Orthop Surg. 2024;16(7):1517-29. https://doi.org/10.1111/os.14077 [9] Woods DA, Loganathan K. Recorrência do ombro congelado após manipulação sob anestesia (MUA). Bone Joint J. 2017;99-B(6):812-7. https://doi.org/10.1302/0301-620X.99B6.BJJ-2016-1133.R1 [10] Fairclough A, Waters C, Davies T, Ali A, Woods D. Recorrência a longo prazo do ombro congelado após manipulação sob anestesia. Shoulder Elbow. 2023;15(2):173-80. https://doi.org/10.1177/17585732211070007 [11] Ranalletta M, Rossi LA, Zaidenberg EE, Bertona A, Tanoira I, Maignon GD, et al. Resultados intermediários após liberação capsular anteroinferior artroscópica para o tratamento de capsulite adesiva idiopática. Arthroscopy. 2017;33(3):503-8. https://doi.org/10.1016/j.arthro.2016.08.024 [12] Mardani-Kivi M, Hashemi-Motlagh K, Darabipour Z. Liberação capsular artroscópica do ombro congelado: resultados intermediários. Clin Shoulder Elb. 2021;24(3):172-7. https://doi.org/10.5397/cise.2021.00311 [13] Pasqualini I, Tanoira I, Hurley ET, Ranalletta M, Rossi LA. A liberação capsular artroscópica alcança resultados clinicamente significativos em pacientes com capsulite adesiva. Arthroscopy. 2024;40(4):1081-8. https://doi.org/10.1016/j.arthro.2023.08.083 [14] Pasqualini I, Rossi LA, Oyem PC, Tanoira I, Ranalletta M. Tempo necessário para alcançar resultados clinicamente significativos após liberação capsular artroscópica. Orthop J Sports Med. 2024;12(11):23259671241275653. https://doi.org/10.1177/23259671241275653 [15] Sedlinsch A, Berndt T, Rühmann O, Lerch S. Convalescença após liberação capsular artroscópica no ombro congelado. J Orthop. 2020;20:374-9. https://doi.org/10.1016/j.jor.2020.06.013 [16] Schoch B, Huttman D, Syed UA, et al. Tratamento cirúrgico da capsulite adesiva: uma comparação de manipulação, liberação capsular e ambas. Cureus. 2020;12(7):e9032. https://doi.org/10.7759/cureus.9032 [17] Sivasubramanian H, Chua CXK, Lim SY, Manohara R, Ng ZWD, Prem Kumar V, et al. Liberação capsular artroscópica para tratar ombro congelado idiopático: quanto de liberação é necessária? Orthop Traumatol Surg Res. 2021;107(1):102766. https://doi.org/10.1016/j.otsr.2020.102766

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

Frozen shoulder management guidelines provide evidence-based guidance and identify key areas for future research [2].
Magnetic resonance imaging findings in frozen shoulder should not replace clinical judgments regarding prognosis and treatment decisions [7].
Clinicians should monitor frozen shoulder patients with diabetes more closely and offer further treatment if pain or lack of function persist long-term [8].
Different treatment strategies for frozen shoulder may be appropriate depending on the location [9].
A strict definition of recalcitrant idiopathic frozen shoulder is needed to prevent unnecessary interventions, as current data should not be interpreted as a plea for surgery in patients with a mean symptom duration of 4 months [10].
The variety of participants, methods, interventions, and outcomes across trials provides limited new evidence to inform the non-surgical management and treatment of frozen shoulder [14].
Patients with a poor outcome or recurrent symptoms after manipulation under anaesthetic (MUA) should be offered a further MUA, with an expectation of a good outcome and a low complication rate [17].
Early surgical intervention might shorten the overall duration of symptoms in frozen shoulder and is not associated with inferior clinical outcomes compared with late surgical intervention [19].
There is insufficient evidence to reliably recommend a single treatment approach for frozen shoulder [32].
Further treatment was indicated in 41% of patients who could not tolerate more than 20 mL of injection during hydrodilatation [34].
Recurrence of frozen shoulder was more common in primary (33%) versus secondary (16%) cases [34].
Arthroscopic capsular release is a suitable option for refractory primary frozen shoulder syndrome, leading to faster and long-lasting recovery [35].
Manipulation under anaesthetic (MUA) and arthroscopic capsular release (ACR) are both good treatment options for primary frozen shoulder [70].
MUA is simpler but carries risks of serious complications, whereas ACR may be safer if performed by experienced surgeons and is convenient for patients with combined rotator cuff tears [70].

Anatomy & Pathophysiology

Primary (idiopathic) frozen shoulder consists of three phases: pain, stiffness, and thawing [3].
Secondary frozen shoulders may not exhibit all three phases and may not follow the exact chronology of primary frozen shoulder [3].
The pain phase of primary frozen shoulder involves a gradual onset of diffuse shoulder pain that is progressive over weeks to months [3].
Pain in the initial phase is usually worse at night and exacerbated by lying on the affected side [3].
Reduced arm use due to pain leads to stiffness [3].
The stiffness phase begins when patients restrict movement to seek pain relief and usually lasts 4 to 12 months [3].
During the stiffness phase, patients experience difficulty with activities of daily living, such as men accessing back pockets or women fastening brassieres [3].
A dull ache is present nearly all time during the stiffness phase, especially at night, often accompanied by sharp pain during range of motion at or near new endpoints [3].
The thawing phase lasts for weeks or months, during which motion increases and pain diminishes [3].
Without treatment, motion return in the thawing phase is gradual and may never objectively return to normal, although most patients subjectively feel near normal [3].
Frozen shoulder is characterized by progressive pain and stiffness that usually resolves spontaneously after about 18 months [4].
Histological features of frozen shoulder are reminiscent of Dupuytren’s disease, with active fibroblastic and myofibroblastic proliferation in the rotator interval, anterior capsule, and coracohumeral ligament [4].
Conditions particularly associated with frozen shoulder include diabetes, Dupuytren’s disease, hyperlipidaemia, hyperthyroidism, cardiac disease, and hemiplegia [4].
The etiology of frozen shoulder is still not known and understanding of the pathogenesis is limited [15].
Frozen shoulder is a poorly understood condition that typically involves substantial pain, movement restriction, and considerable morbidity [12].
The pathophysiology of frozen shoulder is complex, involving various pathophysiologic mechanisms [62].
A systematic review summarizes the tissue pathophysiology of primary frozen shoulder [25].
Primary frozen shoulder is defined by total elevation restricted to 135° or less [20].
In primary frozen shoulder, motion restriction is localized to the humero-scapular joint [20].
Primary frozen shoulder excludes cases with post-traumatic conditions, rheumatoid arthritis, osteoarthritis, hemiplegia, or other obvious changes explaining the range of motion decrease [20].
Secondary frozen shoulder involves decreased range of motion following a traumatic lesion, including soft tissue injury, intra- and juxtaarticular fractures, and other upper limb fractures [20].
Symptomatic subjects with frozen shoulder demonstrate substantial kinematic deficits during humeral range of motion [44].
Patients with frozen shoulder present with altered shoulder muscle activity and kinematics [78].
Pathomechanics of frozen shoulder are characterized by glenohumeral motion limitations, high tension in the anteroinferior glenohumeral capsule, and altered scapular motion [75].
The scapulohumeral rhythm (SHR) of the affected shoulder is inversely related to the severity of limitation of shoulder range of motion, suggesting a compensatory pattern [80].
The anatomical structure of passive shoulder restraints has no impact on the difference in passive joint position sense values between external and internal rotation in frozen shoulder [59].
The thickness of the inferior glenohumeral joint capsule in the 80° scapular plane elevated arm position is a highly reliable and valid method for assessment [79].
Imaging is an essential tool for evaluation of patients with shoulder pain to understand the extent of injury [37].
X-rays in frozen shoulder are normal, and their main role is to exclude other causes of pain and stiffness [4].
Post-traumatic stiffness may persist for some months after severe shoulder injury but is maximal at the start and gradually lessens, unlike the pattern of frozen shoulder [4].
Disuse stiffness can occur if the arm is nursed overcautiously, such as following a wrist fracture, but lacks the characteristic pain pattern of frozen shoulder [4].
Complex regional pain syndrome may follow acute trauma or be seen in patients with myocardial infarction or stroke, presenting features similar to frozen shoulder [4].
Rheumatoid arthritis and osteoarthritis can affect the shoulder and develop bilaterally, with diagnosis usually obvious on X-ray [4].
Shoulder stiffness is a typical outcome after bone or soft tissue injuries around the shoulder, including contusions, subluxations, dislocations, acromioclavicular joint injuries, clavicle and scapula fractures, and proximal humerus fractures in the elderly [61].
Repetitive, low-level trauma can cause localized contractures leading to motion loss in specific patterns [61].
Isolated posterior capsular contracture is the most commonly described localized contracture causing motion loss [61].
Surgical procedures such as anterior or posterior capsulorrhaphy, inferior capsular shift, and rotator cuff surgery can result in limitation of motion [61].

Classification

Frozen shoulder is a specific, painful, and debilitating condition affecting patients mainly in middle age [6].
Most patients clinically diagnosed with primary frozen shoulder had undiagnosed systemic abnormalities and/or intra-articular pathologies [5].
18F-FDG PET/CT is clinically relevant in diagnostically challenging cases, such as distinguishing the first phase of frozen shoulder from subacromial impingement [11].
Health professionals manage frozen shoulders differently for different phases of the condition [16].
Primary frozen shoulders are defined by total elevation restricted to 135° or less [20].
In primary frozen shoulder, the restriction of motion is localized to the humero-scapular joint [20].
Primary frozen shoulder is diagnosed when no findings in case history, clinical examination, or radiological examination explain the decrease in range of motion [20].
Cases with post-traumatic conditions, rheumatoid arthritis, osteoarthritis, hemiplegia, and other obvious changes are excluded from primary frozen shoulder classification [20].
Secondary frozen shoulder is characterized by decreased range of motion following a traumatic lesion [20].
Associated injuries in secondary frozen shoulder include soft tissue injury to the shoulder region, intra- and juxtaarticular fractures, and other fractures of the upper limb [20].
Frozen shoulder is classified into three consecutive stages according to Reeves [20].
Stage 1 of frozen shoulder is characterized by pain [20].
Stage 1 of frozen shoulder has a duration of 10 to 36 weeks [20].
In Stage 1 of frozen shoulder, there is no difference between men and women, no difference between affected dominant and nondominant shoulders, and no correlation with age [20].
In the early stages of frozen shoulder, there is a full range of movement under anesthesia [20].
Classification of frozen shoulder was found to be controversial [38].
There are lower rates of agreement among Japan Shoulder Society (JSS) members than American Shoulder and Elbow Surgeons (ASES) members for the definition of primary frozen shoulder [43].
There are lower rates of agreement among JSS members than ASES members for the classification of primary and secondary frozen shoulder [43].
There are lower rates of agreement among JSS members than ASES members for the divisions of secondary frozen shoulder [43].
There is disagreement among shoulder specialists regarding terminology for frozen shoulder [57].

Clinical Presentation

Frozen shoulder is a specific, painful, and debilitating condition that primarily affects patients in middle age [6].
Frozen shoulder is a common disease that causes significant morbidity [21].
Frozen shoulder is characterized by severe shoulder pain and functional restriction [24].
Frozen shoulder has considerable economic impact [28].
Frozen shoulder typically involves substantial pain, movement restriction, and considerable morbidity [12].
Frozen shoulder affects approximately 4% of the general population [24].
Frozen shoulder affects up to 59% of patients with diabetes mellitus [24].
The disease duration of frozen shoulder varies between 1 and 3 years [24].
The clinical course of primary (idiopathic) frozen shoulder consists of three phases: pain, stiffness, and thawing [3].
Primary frozen shoulder is characterized by progressive pain and stiffness which usually resolves spontaneously after about 18 months [4].
In Phase I (Pain), patients experience a gradual onset of diffuse shoulder pain that is progressive over weeks to months [3].
The pain in Phase I is usually worse at night and exacerbated by lying on the affected side [3].
In Phase II (Stiffness), patients restrict movement to seek pain relief, leading to stiffness that usually lasts 4 to 12 months [3].
During Phase II, patients have difficulty with activities of daily living, such as men reaching back pockets or women fastening brassieres [3].
In Phase II, a dull ache is present nearly all the time, especially at night, often accompanied by sharp pain during range of motion at or near new endpoints [3].
In Phase III (Thawing), motion increases and pain diminishes over weeks or months [3].
Without treatment, motion return in Phase III is gradual and may never objectively return to normal, though patients often subjectively feel near normal [3].
The natural history of frozen shoulder involves pain that increases in severity, prevents sleeping on the affected side, and subsides after several months [4].
As pain subsides in frozen shoulder, stiffness becomes more prominent and persists for another 6–12 months if untreated [4].
Movement is gradually regained in frozen shoulder but may not return to normal [4].
Patients with frozen shoulder are typically aged 40–60 years [4].
Patients with frozen shoulder may give a history of trauma, often trivial, followed by pain [4].
Physical examination of frozen shoulder usually reveals slight muscle wasting and tenderness [4].
Movements in frozen shoulder are always limited, and the shoulder may be extremely stiff in severe cases [4].
X-rays in frozen shoulder are normal; their main role is to exclude other causes of pain and stiffness [4].
Post-traumatic stiffness is characterized by stiffness without much pain that is maximal at the start and gradually lessens, unlike the pattern of frozen shoulder [4].
Disuse stiffness occurs if the arm is nursed overcautiously and lacks the characteristic pain pattern of frozen shoulder [4].
Complex regional pain syndrome may follow acute trauma or occur in patients with myocardial infarction or stroke, presenting features similar to frozen shoulder [4].
Rheumatoid arthritis and osteoarthritis can affect the shoulder bilaterally and are usually obvious on X-ray [4].
Primary frozen shoulder excludes cases with post-traumatic conditions, rheumatoid arthritis, osteoarthritis, hemiplegia, or other obvious changes in history or examination [20].
Secondary frozen shoulder involves decreased range of motion following a traumatic lesion, such as soft tissue injury or fractures of the upper limb [20].
Stage 1 (pain) of frozen shoulder lasts 10 to 36 weeks [20].
In Stage 1 of frozen shoulder, there is no difference in presentation between men and women, affected dominant and nondominant shoulders, or correlation with age [20].
Frozen shoulder following COVID-19 vaccination may present with clinical features similar to idiopathic frozen shoulder [39].
Frozen shoulder can occur after COVID-19 vaccination [41].
Frozen shoulder is particularly associated with diabetes, Dupuytren’s disease, hyperlipidaemia, hyperthyroidism, cardiac disease, and hemiplegia [4].
MR findings in frozen shoulder should not replace clinical judgments regarding further prognosis and treatment decisions [7].
Unusual stiffness and pain in the shoulder of a young female patient suggests a wide range of disease entities, including infection [23].
Misdiagnosing shoulder tumors as frozen shoulder syndrome is likely to cause a significant delay in making a correct diagnosis [40].
A detailed clinical history and examination is critical in the assessment of a painful, stiff shoulder to avoid misdiagnosis of conditions like malignant shoulder girdle tumours [1].

Investigations

A detailed clinical history and examination is critical in the assessment of a painful, stiff shoulder [1].
The term frozen shoulder should be reserved for a well-defined disorder characterized by progressive pain and stiffness which usually resolves spontaneously after about 18 months [4].
The histological features of frozen shoulder are reminiscent of Dupuytren’s disease, with active fibroblastic and myofibroblastic proliferation in the rotator interval, anterior capsule and coracohumeral ligament [4].
Patients may give a history of trauma, often trivial, followed by pain that gradually increases in severity and often prevents sleeping on the affected side [4].
Pain begins to subside after several months, but stiffness becomes more problematic; untreated stiffness persists for another 6–12 months before movement is gradually regained, which may not return to normal [4].
Clinical examination usually reveals slight muscle wasting and tenderness, with always limited movements and extreme stiffness in severe cases [4].
X-rays are normal in frozen shoulder, and their main role is to exclude other causes of pain and stiffness [4].
Disuse stiffness may occur if the arm is nursed overcautiously, such as following a wrist fracture, and lacks the characteristic pain pattern of frozen shoulder [4].
Complex regional pain syndrome may follow acute trauma or be seen in patients with myocardial infarction or stroke, and its features can be similar to those of frozen shoulder [4].
Both rheumatoid arthritis and osteoarthritis can affect the shoulder, with diagnosis usually obvious on X-ray, and rheumatoid arthritis may present with characteristic generalized symptoms and signs [4].
Unusual stiffness and pain in the shoulder of a young female patient suggests a wide range of disease entities, from simple frozen shoulder to infection [23].
Routine use of shoulder MRI scans in patients with frozen shoulder but without suspicion of additional pathology may not be indicated [31].
Imaging is an essential tool for evaluation of patients with shoulder pain, and understanding the extent of an injury with imaging is key to successful management [37].
Physicians should re-examine frozen shoulder patients with repeated plain radiographs and further imaging, especially MRI, if conservative therapy fails [56].
MR arthrography reveals characteristic findings in patients with frozen shoulder [58].
T2 signal hyperintensity and axillary capsule thickening are characteristic of the early stages of frozen shoulder, although MRI alone cannot completely define the disease stage [71].
The burning sign is an abnormal finding that appears in dynamic MRI of severe frozen shoulder [73].
Dynamic MRI semiquantitatively demonstrated a reduction in abnormal blood flow and improvement in clinical results after manipulation under cervical nerve root block (MUC) in patients with frozen shoulder [77].
Clinical improvement in patients with frozen shoulder was associated with a decrease in the coefficient of enhancement (CE) in the glenohumeral synovium following intraarticular injections of hyaluronate [81].
There may be a causal relationship between hypothyroidism and frozen shoulder [85].
Patients who underwent image-guided (ultrasound) injections had statistically significant greater improvement in shoulder pain and function at 6 weeks after injection compared to blind injections [86].
MR imaging of patients with severe frozen shoulder after MUC showed 29 capsule tears, 4 labrum tears, and 15 bone bruises of the humeral head [87].

Treatment

Non-Operative Management

Treatment for frozen shoulder aims to improve pain and function through a shared decision-making process, utilizing a step-up approach from conservative measures to invasive treatments if symptoms persist [28].
Health professionals manage frozen shoulders differently depending on the phase of the condition [16].
There is limited evidence of the effectiveness of different forms of treatment used for frozen shoulder, with many studies carrying a moderate to high risk of bias and omitting details of symptom duration or condition phase [74].
The variety of participants, methods, interventions, and outcomes across trials provides limited new evidence to inform non-surgical management [14].
Conservative treatment is effective for the treatment of frozen shoulder regardless of the severity of symptoms [45].
Intra-articular steroid injection is effective and safe for frozen shoulder, relieving pain, improving functional performance, and increasing range of motion [48].
Multisite corticosteroid injection therapy is more effective than single intra-articular injection in terms of pain relief, restoration of motion, and functional status for primary frozen shoulder [46].
Both multisite and single glenohumeral injections of corticosteroid are effective in patients with primary frozen shoulder [49].
Ultrasound-guided administration of corticosteroid injections into the glenohumeral joint increases the likelihood of successful injection but does not improve clinical outcomes at 12 weeks compared with blind administration [52].
Ultrasound-guided multisite injection is a nonsurgical treatment technique for frozen shoulder that emphasizes correct injection sites [72].
Hydrodilatation has emerged as a potential nonsurgical option in the management of frozen shoulder, but its role has yet to be fully clarified [60].
Management of frozen shoulder stage II to III using hydrodistension and a guided exercise programme by physiotherapists in primary care is an effective non-operative treatment strategy [66].
Recurrence of frozen shoulder after hydrodilatation was more common in primary (33%) versus secondary (16%) frozen shoulder [34].
A central nervous system-focused treatment approach is being evaluated in a randomized clinical trial to compare effectiveness against standard medical and physical therapy care [42].
The comparative effectiveness of low-level laser therapy versus muscle energy technique is being evaluated in a randomized controlled trial to determine the optimal treatment approach for frozen shoulder related to diabetes [47].

Operative and Procedural Management

Secondary frozen shoulder may be more recalcitrant to conventional conservative treatment [64].
The study on arthroscopic capsular release timing adds information for shared decision-making but should not be a plea for surgery for patients with a mean duration of symptoms of 4 months; a strict definition of recalcitrant idiopathic frozen shoulder is needed to prevent unnecessary interventions [10].
The arthroscopic 360° release is an effective and safe treatment modality for severe or recalcitrant frozen shoulder [53].
A combination of limited capsular release and manipulation under anaesthesia (MUA) for primary frozen shoulder is a safe and effective procedure resulting in marked improvement in pain, function, and range of motion [55].
The mid-term outcomes of transcatheter arterial micro embolization (TAME) for frozen shoulders resistant to conservative treatments are encouraging and warrant further evaluation [50].
Manipulation under anesthesia versus physiotherapy treatment in stage two of a frozen shoulder is being evaluated in a randomized controlled trial to provide evidence on the best treatment strategy [51].
Different treatment strategies for frozen shoulder may be appropriate depending on the location of pathology [9].

Complications

Frozen shoulder is a painful and debilitating condition [6].
Frozen shoulder causes significant morbidity [21].
The natural history of primary frozen shoulder consists of three phases: pain, stiffness, and thawing [3].
Primary frozen shoulder usually resolves spontaneously after about 18 months [4].
Without treatment, motion return in primary frozen shoulder is gradual and may never objectively return to normal [3].
In the long term, 41% of patients with frozen shoulder report some ongoing symptoms [30].
Postoperative frozen shoulder is a serious complication after shoulder surgery with an incidence of 11% [54].
Preoperative frozen shoulder negatively affects functional outcomes, including range of motion, at 6 months and 1 year postoperatively following arthroscopic rotator cuff repair [33].
Preoperative frozen shoulder positively affects rotator cuff healing [33].
Patients with diabetes should be monitored more closely for frozen shoulder, as they may experience persistent pain or lack of function long-term [8].
An age between 46 and 60 years is a statistically significant risk factor for developing frozen shoulder after simple arthroscopic shoulder procedures [29].
A previous history of contralateral frozen shoulder is a statistically significant risk factor for developing frozen shoulder after simple arthroscopic shoulder procedures [29].
Most patients clinically diagnosed with primary frozen shoulder have undiagnosed systemic abnormalities and/or intra-articular pathologies [5].
Recurrence of frozen shoulder after manipulation under anaesthetic (MUA) can occur, but late recurrence is uncommon [22].
Patients with poor outcomes or recurrent symptoms after MUA can be offered a further MUA with an expectation of good outcome and low complication rate [17].

Recovery

Phase I (Pain) involves a gradual onset of diffuse shoulder pain that is progressive over weeks to months [3].
Pain in Phase I is usually worse at night and exacerbated by lying on the affected side [3].
Phase II (Stiffness) usually lasts 4 to 12 months [3].
During Phase II, patients restrict movement to seek pain relief, leading to difficulty with activities of daily living such as reaching back pockets or fastening brassieres [3].
Phase II is accompanied by a dull ache present nearly all the time, especially at night, and sharp pain during range of motion at or near new endpoints [3].
Phase III (Thawing) lasts for weeks or months, during which motion increases and pain diminishes [3].
Without treatment, motion return in Phase III is gradual in most patients [3].
Objective motion may never return to normal, although most patients subjectively feel near normal due to compensation or adjustment in activities of daily living [3].
Frozen shoulder affects approximately 4% of the general population and up to 59% in patients with diabetes mellitus [24].
In the long term, 59% of patients with frozen shoulder have normal or near normal shoulders [30].
94% of patients with spontaneous frozen shoulder recover to normal levels of function and motion without treatment [69].
Idiopathic frozen shoulder is a self-limiting condition in which symptoms subside and full shoulder movement returns within a maximum of two years from the onset of symptoms [88].
Long-term outcome after manipulation under anaesthetic (MUA) for frozen shoulder is favourable with late recurrence being uncommon [22].
Patients with poor outcome or recurrent symptoms after MUA should be offered a further MUA with the expectation of a good outcome and a low complication rate [17].
Arthroscopic capsular release leads to a faster and long-lasting recovery in patients with refractory primary frozen shoulder syndrome [35].
The long-term results of arthroscopic capsular release in frozen shoulder were confirmed in 255 patients [36].
MUA in stage 2 frozen shoulder results in a faster recovery of range of motion and improved functional outcome compared to physiotherapy alone in the short term [68].
MUA in stage 2 frozen shoulder can be considered safe compared to physiotherapy alone in the short term [68].
Early surgical intervention might shorten the overall duration of symptoms in frozen shoulder [19].
Early surgical intervention is not associated with inferior clinical outcomes when compared with late surgical intervention [19].
Timing has a significant influence on the outcome of manipulation for frozen shoulders [90].
Diabetes is a poor prognostic factor for the conservative treatment of frozen shoulder [82].
Male sex is a poor prognostic factor for the conservative treatment of frozen shoulder [82].
Simultaneous bilateral involvement is a poor prognostic factor for the conservative treatment of frozen shoulder [82].
Subsequent bilateral involvement is a poor prognostic factor for the conservative treatment of frozen shoulder [82].
A longer duration of symptoms recorded at the first visit is a poor prognostic factor for the conservative treatment of frozen shoulder [82].
Preoperative frozen shoulder negatively affected most functional outcomes, including range of motion, at 6 months and 1 year postoperatively after arthroscopic rotator cuff repair [33].
Preoperative frozen shoulder positively affected rotator cuff healing after arthroscopic rotator cuff repair [33].

Key Evidence

[L4] A detailed clinical history and examination is critical in the assessment of a painful, stiff shoulder. [1] (10.1186/1477-7800-2-2)
[L1] This updated guideline provides evidence-based guidance for managing frozen shoulder and identifies key areas for future research. [2] (10.1177/17585732251335955)
[L4] Most patients clinically diagnosed with primary frozen shoulder had undiagnosed systemic abnormalities and/or intra-articular pathologies. [5] (10.5397/cise.2018.21.2.82)
[Paper] Frozen shoulder is a specific, painful and debilitating condition effecting patients mainly in middle age. [6] (10.1016/j.maturitas.2014.02.009)
[L4] MR findings in frozen shoulder should not replace clinical judgments regarding further prognosis and treatment decisions. [7] (10.1007/s00167-015-3887-y)
[L2] If high-quality studies can confirm the findings of this review, then clinicians should monitor frozen shoulder patients with diabetes more closely and offer further treatment if pain or lack of function persist long-term. [8] (10.1016/j.arrct.2021.100141)
[L5] Different treatment strategies for frozen shoulder may be appropriate, depending on the location. [9] (10.1016/j.jse.2018.03.010)
[L5] The study adds information for shared decision-making but should not be a plea for surgery for patients with a mean duration of symptoms of 4 months; a strict definition of recalcitrant idiopathic frozen shoulder is needed to prevent unnecessary interventions. [10] (10.1177/2325967120903710)
[L2] This is clinically relevant in diagnostically challenging cases, for instance in the first phase of frozen shoulder, which can be difficult to distinguish from subacromial impingement. [11] (10.1007/s00167-020-05937-2)
[L5] Frozen shoulder is a poorly understood condition that typically involves substantial pain, movement restriction, and considerable morbidity. [12] (10.1016/j.math.2014.07.006)
[L1] The variety of participants included/excluded in trials and the variety of methods, interventions and outcomes used across the trials provided limited new evidence to inform the non-surgical management and treatment of people with frozen shoulder. [14] (10.2340/16501977-2578)
[L4] The etiology of frozen shoulder is still not known and our understanding of the pathogenesis is limited. [15] (10.3109/03009749009096786)
[L4] Health professionals manage frozen shoulders differently for different phases of the condition. [16] (10.1111/j.1758-5740.2010.00073.x)
[L4] Patients with a poor outcome or recurrent symptoms of a frozen shoulder after a MUA should be offered a further MUA with the expectation of a good outcome and a low complication rate. [17] (10.1302/0301-620x.99b6.bjj-2016-1133.r1)
[L3] Early surgical intervention might shorten the overall duration of symptoms in frozen shoulder and is not associated with inferior clinical outcomes when compared with late surgical intervention. [19] (10.1016/j.jse.2020.07.023)
[L4] Frozen shoulder is a common disease which causes significant morbidity. [21] (10.5312/wjo.v6.i2.263)
[L3] Long-term outcome after MUA for frozen shoulder is favourable with late recurrence being uncommon. [22] (10.1177/17585732211070007)
[L5] Unusual stiffness and pain in the shoulder of a young female patients suggests a wide range of disease entities, from simple frozen shoulder to (albeit rarely) infection. [23] (10.1016/j.radcr.2020.08.006)
[L1] This systematic review presents a summary of what is currently known about the tissue pathophysiology of primary frozen shoulder. [25] (10.1186/s12891-016-1190-9)
[L4] Frozen shoulder is a painful and debilitating condition with considerable economic impact; treatment aims to improve pain and function through a shared decision-making process, with a step-up approach from conservative measures to invasive treatments if symptoms persist. [28] (10.1177/1758573215601779)
[L3] An age of between 46 and 60 years and a previous history of contralateral frozen shoulder were statistically significant risk factors. [29] (10.1302/0301-620x.97b7.35387)
[L3] In the long term, 59% of patients had normal or near normal shoulders and 41% reported some ongoing symptoms. [30] (10.1016/j.jse.2007.05.009)
[L4] Therefore, routine use of shoulder MRI scans in patients with FS but without suspicion of an additional pathology may not be indicated. [31] (10.1016/j.jseint.2022.05.009)
[L1] There is insufficient evidence to reliably recommend a treatment approach for frozen shoulder. [32] (10.1136/bmj.i4162)
[L3] Preoperative frozen shoulder positively affected rotator cuff healing but negatively affected most functional outcomes, including ROM, at 6 months and 1 year postoperatively. [33] (10.1177/2325967120934449)
[L4] Further treatment was indicated in 41% of patients who could not tolerate more than 20 mL of injection, and recurrence was more common in primary (33%) versus secondary (16%) frozen shoulder. [34] (10.1177/17585732221124914)
[Paper] In patients with refractory primary frozen shoulder syndrome, arthroscopic capsular release emerges as a suitable option that leads to a faster and long-lasting recovery. [35] (10.1016/j.eats.2015.06.004)
[L4] The long-term results of arthroscopic capsular release in frozen shoulder were confirmed in 255 patients. [36] (10.1186/s13018-018-0758-5)
[L4] Imaging is an essential tool for evaluation of patients with shoulder pain; understanding the extent of an injury with imaging is key to successful management. [37] (10.1016/j.csm.2013.03.009)
[L4] However, classification of frozen shoulder was found to be controversial. [38] (10.4055/cios.2020.12.1.60)
[L4] Frozen shoulder following COVID-19 vaccination may present with clinical features similar to those of idiopathic frozen shoulder. [39] (10.1016/j.xrrt.2023.09.013)
[L2] Misdiagnosing shoulder tumors as frozen shoulder syndrome is likely to cause a significant delay in making a correct diagnosis. [40] (10.1016/j.jse.2009.05.010)
[L4] Frozen shoulder can occur after COVID-19 vaccination, and musculoskeletal specialists should be aware of this diagnosis to identify and treat such patients early. [41] (10.1016/j.jseint.2022.02.013)
[Paper] The trial aims to compare the effectiveness of a CNS-directed treatment program versus standard medical and physical therapy care on outcomes in participants with frozen shoulder. [42] (10.1186/s13063-019-3585-z)
[L4] The survey shows lower rates of agreement among the JSS members than the ASES members for the definition of primary frozen shoulder, the classification of primary and secondary frozen shoulder, and the divisions of secondary frozen shoulder. [43] (10.1016/j.jos.2018.12.012)
[L4] Symptomatic subjects demonstrated substantial kinematic deficits during humeral range of motion. [44] (10.1016/s0003-9993(03)00359-9)
[L3] Conservative treatment is effective for the treatment of frozen shoulder. [45] (10.1016/j.asmr.2025.101149)
[Commentary] Multisite corticosteroid injection therapy is more effective in terms of pain relief, restoration of motion, and functional status than single intra-articular injection for the treatment of primary frozen shoulder. [46] (10.1016/j.arthro.2021.02.028)
[L2] The findings of the study may provide evidence on the efficacy of these interventions and most likely, the optimal treatment approach for frozen shoulder related to diabetes, which may guide clinical practice. [47] (10.1186/s13018-024-04735-7)
[L1] Intra-articular steroid injection is effective and safe for frozen shoulder, relieving pain, improving functional performance, and increasing range of motion. [48] (10.1177/0363546516669944)
[L1] Both treatments were effective in patients with primary frozen shoulder. [49] (10.1016/j.arthro.2021.01.069)
[Abstract] The mid-term outcomes of TAME for frozen shoulders that were resistant to conservative treatments are encouraging and warrant further evaluation. [50] (10.1016/j.jse.2016.11.031)
[L2] Successful completion of this trial will provide evidence on the best treatment strategy for patients with a stage two frozen shoulder. [51] (10.1186/s12891-017-1763-2)
[L1] In patients with frozen shoulder, US-guided administration of corticosteroid injections into the glenohumeral joint increased the likelihood of successful injection but did not improve clinical outcomes at 12 weeks compared with blind administration. [52] (10.2106/jbjs.21.01007)
[L4] The arthroscopic 360° release is an effective and safe treatment modality for severe or recalcitrant frozen shoulder. [53] (10.1016/j.jseint.2024.07.006)
[L2] Postoperative frozen shoulder is a serious complication after shoulder surgery, with an incidence of 11%. [54] (10.1007/s00402-016-2589-3)
[L4] A combination of limited capsular release and MUA for the treatment of primary frozen shoulder is a safe and effective procedure resulting in marked improvement in pain, function and range of motion. [55] (10.1177/1758573215578590)
[L4] Physicians should re-examine frozen shoulder patients with repeated plain radiographs and further imaging, especially MRI, if conservative therapy fails. [56] (10.1016/j.jse.2011.07.026)
[L4] This survey summarized the trend in prevalent practices regarding frozen shoulder among shoulder specialists and senior shoulder surgeons of SESI, revealing strong consensus on imaging and nonoperative management but disagreement on terminology and specific surgical complications. [57] (10.1177/23259671221118834)
[L4] MR arthrography reveals characteristic findings in patients with frozen shoulder. [58] (10.1148/radiol.2332031219)
[L3] The anatomical structure of passive shoulder restraints has no impact on the difference in passive joint position sense values between external and internal rotation. [59] (10.1186/s12891-016-0971-5)
[L5] Hydrodilatation has emerged as a potential nonsurgical option in the management of frozen shoulder, but its role has yet to be fully clarified. [60] (10.1302/2058-5241.2.160061)
[L5] This scoping review outlines the complexity of the pathophysiology of frozen shoulder and provides a comprehensive overview of pathophysiologic mechanisms. [62] (10.1186/s40634-020-00307-w)
[L4] Secondary frozen shoulder may be more recalcitrant to conventional conservative treatment. [64] (10.1016/j.jor.2015.01.030)
[L4] This service evaluation demonstrates that management of frozen shoulder stage II to III, as conducted by physiotherapists in a primary care setting utilizing hydrodistension and a guided exercise programme, represents an effective non-operative treatment strategy. [66] (10.1177/1758573217701063)
[L1] MUA in stage 2 frozen shoulder can be considered safe and results in a faster recovery of range of motion and improved functional outcome compared to physiotherapy alone in the short term. [68] (10.1016/j.jseint.2023.11.004)
[L4] We found 94% of patients with spontaneous frozen shoulder recovered to normal levels of function and motion without treatment. [69] (10.1007/s11999-011-2176-4)
[L5] MUA and ACR are good treatment options for primary frozen shoulder; MUA is simpler but carries risks of serious complications, while ACR may be safer if performed by experienced surgeons and is convenient for patients with combined rotator cuff tears. [70] (10.5397/cise.2020.00311)
[L5] T2 signal hyperintensity and axillary capsule thickening are characteristic of the early stages of frozen shoulder, although MRI alone cannot completely define the disease stage. [71] (10.1016/j.xrrt.2024.05.002)
[L5] This technique is presented for the nonsurgical treatment of frozen shoulder, emphasizing correct injection sites. [72] (10.1016/j.eats.2022.06.020)
[L4] The burning sign is an abnormal finding that appears in dynamic MRI of severe frozen shoulder. [73] (10.1016/j.jse.2016.06.003)
[L2] There is limited evidence of the effectiveness of different forms of treatment used for frozen shoulder, with many studies evaluating treatment effects carrying a moderate to high risk of bias and omitting details of the duration of symptoms or the phase of the condition. [74] (10.1111/j.1758-5740.2010.00067.x)
[L5] Pathomechanics of the frozen shoulder characterised by glenohumeral motion limitations should be considered complicated, as confirmed by high tension in the anteroinferior glenohumeral capsule and altered scapular motion. [75] (10.1016/j.jseint.2025.04.003)
[L4] Dynamic MRI semiquantitatively demonstrated a reduction in abnormal blood flow and improvement in clinical results after MUC in patients with frozen shoulder. [77] (10.1016/j.jseint.2021.12.007)
[L4] Patients with frozen shoulder presented with altered shoulder muscle activity and kinematics, and one-session of heat and manual muscle release showed beneficial effects on shoulder muscle performance, kinematics, mobility, and pain. [78] (10.1186/s12891-017-1867-8)
[L3] The thickness of the inferior glenohumeral joint capsule in the 80° scapular plane elevated arm position was shown to be a highly reliable and valid method. [79] (10.1016/j.jseint.2024.06.004)
[L4] SHR of the affected shoulder is inversely related to severity of limitation of shoulder range of motion, which suggests a compensatory pattern. [80] (10.1016/j.jbiomech.2007.09.004)
[L4] Clinical improvement in patients with frozen shoulder was associated with a decrease in the coefficient of enhancement (CE) in the glenohumeral synovium. [81] (10.1007/s00776-004-0766-7)
[L2] Diabetes, male sex, simultaneous bilateral involvement, subsequent bilateral involvement, and a longer duration of symptoms recorded at the first visit were identified as poor prognostic factors for the conservative treatment of frozen shoulder. [82] (10.1016/j.jos.2019.03.011)
[L2] Our MR analysis suggests that there may be a causal relationship between hypothyroidism and frozen shoulder. [85] (10.1186/s12891-024-07826-y)
[L1] Patients who underwent image-guided (ultrasound) injections had statistically significant greater improvement in shoulder pain and function at 6 weeks after injection compared to blind injections. [86] (10.1186/1471-2474-12-137)
[L4] MR imaging of patients with severe frozen shoulder after MUC showed 29 capsule tears, 4 labrum tears, and 15 bone bruises of the humeral head. [87] (10.1016/j.jse.2015.06.019)
[L4] In the great majority of patients idiopathic frozen shoulder is a self-limiting condition, in which symptoms subside and full shoulder movement returns within a maximum of two years from the onset of symptoms. [88] (10.2106/00004623-197860040-00030)
[L4] In the great majority of patients idiopathic frozen shoulder is a self-limiting condition, in which symptoms subside and full shoulder movement returns within a maximum of two years from the onset of symptoms. [89] (10.2106/00004623-197860040-00029)
[L4] Timing has a significant influence on the outcome of manipulation for frozen shoulders. [90] (10.1016/j.jos.2020.11.002)

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