Spalla congelata

Sinonimo: capsulite adesiva della spalla

Che cos'è la spalla congelata?

La spalla congelata è una delle cause più comuni di dolore intrinseco alla spalla. È un disturbo glenomerale e può verificarsi in una spalla o in entrambe le spalle contemporaneamente. L'ispessimento e la contrazione della capsula articolare glenomerale e la formazione di aderenze causano dolore e perdita di movimento.¹

La spalla congelata può verificarsi:

• Spontaneamente.

• A seguito di lesioni/traumi alla cuffia dei rotatori.

• In conditions causing immobility - eg, after a cerebrovascular accident or plaster immobilisation.

Vedi il separato Dolore alla spalla e Esame della spalla articoli.

Quanto è comune la spalla congelata? (Epidemiologia)¹²

• La capsulite adesiva si verifica in circa il 2-5% della popolazione con un'incidenza massima tra i 40 e i 70 anni di età.

• It is more common in females and bilateral in 20-30% of cases. When unilateral, the non-dominant hand is more commonly affected.

• The incidence of adhesive capsulitis is more common in those with diabetes and thyroid disorders - outcomes are worse in those with a longer duration of diabetes.

Sintomi della spalla congelata¹²

I sintomi principali sono dolore e rigidità, causati dalla formazione di tessuto adesivo o cicatriziale nell'articolazione gleno-omerale.

• There is usually a gradual onset of severe pain in the shoulder, which is then followed by stiffness.

• Restrizione di tutti i movimenti della spalla, sia attivi che passivi.

• Incapacità di dormire sul lato colpito.

• Restriction of activities of daily living due to impaired external rotation - eg, driving and dressing.

• Di solito ci sono tre fasi:

  • Fase 1 - severe generalised pain associated with stiffness. Daily activities are limited (eg, putting on a jacket). It can last up to nine months.

  • Fase 2 - pain usually gradually subsides but the shoulder is stiff. Movement can become more limited. External rotation is usually very limited. This phase lasts between 4-12 months.

  • Fase 3 - the shoulder becomes less stiff. There is an increase in the range of movement. This phase usually lasts 1-3 years.

Rigidità, dolore e perdita di movimento con insorgenza insidiosa sono di solito i sintomi principali.

Diagnosi della spalla congelata (indagini)

• La diagnosi è clinica:

  • L'intera articolazione della spalla può essere sensibile alla palpazione.

  • Il principale test diagnostico è l'incapacità di eseguire la rotazione esterna passiva.

• X-rays are usually only necessary if the presentation is atypical or the patient is not responding to treatment - they are often normal.

• Considera altre cause del dolore alla spalla.

• Blood tests and radiography should only be performed if red flag symptoms are present. For a list of these, refer to the separate Dolore alla spalla articolo.

Trattamento e gestione della spalla congelata^{23 4 5}

Consider referral to secondary care if pain and significant disability are present for more than six months despite appropriate conservative management and always refer if there is diagnostic doubt.

Despite over a hundred years of treating this condition the most efficacious treatments are still largely unclear. A holistic approach to treatment should be used, considering psychological and psychosocial factors.

• La prima fase è l'analgesia - paracetamolo come prima scelta con farmaci antinfiammatori non steroidei (FANS) come seconda scelta, a condizione che non vi siano controindicazioni. L'uso di un dispositivo di stimolazione elettrica transcutanea dei nervi (TENS) può essere utile.

• Incoraggiare l'attività precoce.

• Physiotherapy with joint mobilisation combined with stretching exercises have been shown to be better than stretching exercise alone in terms of external rotation, abduction range of motion and function score, although a 2023 systematic review was limited by lack of consistency in study designs and found that most of the benefits did not reach statistical significance. The 2025 British Elbow and Shoulder Society patient care pathway rates physiotherapy as 'likely to be beneficial'.⁶⁷

• La mobilizzazione passiva e lo stretching capsulare sono due delle tecniche più comunemente utilizzate in fisioterapia.

• Injection with corticosteroids:

  • This can reduce pain and duration of symptoms in the early stages and the 2025 British Elbow and Shoulder Society patient care pathway rates injection as 'likely to be beneficial'.⁶

  • It should not be done if a previous such injection has shown no or minimal benefit, or if the patient has passed the pain stage and entered the stiffness stage.

  • Care must be taken to monitor blood sugar after the injection in patients with diabetes (they may be raised for 1-2 days) and the balance of risks and benefits should be carefully considered in those with poorly controlled diabetes.⁸

• A 2012 Cochrane review found no benefit to an ultrasound guided injection versus one without such guidance. More recent smaller studies are divided, with some finding more pain reduction with ultrasound guidance and others finding no difference - the 2025 British Elbow and Shoulder Society patient care pathway also found that this made no difference. An injection should therefore not be delayed to wait for ultrasound guidance to be available.⁹¹⁰¹¹

• Oral steroids are not recommended, although they may reduce pain in the very short term.⁸

• Surgical options include manipulation under anaesthesia and arthroscopic capsulotomy but are generally reserved for cases where non-surgical options have failed.²

Complicazioni della spalla congelata

Long-term pain and shoulder stiffness are possible complications.

Prognosi della spalla congelata

• 80 - 90% of patients with spontaneous frozen shoulder have been shown to recover to normal levels of function and movement by two years without any treatment, with the remaining 10-20% having some residual stiffness or discomfort.²¹²

• Le recidive nella stessa spalla sono rare.