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Original Article
Incidence and Clinical Profile of Patients with Frozen Shoulder after
Cardiac Surgery
M Chokkalingam1, MBBS, MD, DNB Cardiology; S Saradha2, MBBS, MD, DLO; A Navitha1, BSc, Cardiac Technology;
Pradeep G Nayar1, MBBS, MD, DNB Cardiology

Departments of 1Cardiology Background: Frozen shoulder is a condition characterized by pain and global restriction of

Abstract
and 2Pharmacology, Chettinad movement with loss of external rotation. Cardiac surgery may predispose frozen shoulder as
Hospital and Research patients tend to immobilize their upper limbs after surgery. Objectives: The aim of this study is
Institute, Chennai, to analyze the clinical profile of patients presenting with symptoms of periarthritis shoulder and
Tamil Nadu, India to determine the incidence of frozen shoulder among patients undergoing cardiac surgery as well
as to find the factors associated with its development. Methods: It is a clinical observational
study done in the Cardiology Department of Chettinad Hospital and Research Institute, Chennai,
between August 2015 and May 2016, on 100 patients who underwent cardiac surgery and
attended the follow‑up session as an outpatient. Data were collected by face‑to‑face interview
using a standardized questionnaire. Respondents presenting with pain and restricted movement of
shoulder joint with positive limitation in lateral rotation, abduction, and medial rotation (LAM)
test were considered to have frozen shoulder. Each participant was followed up for 3 months
postcardiac surgery. Results: The mean age of the study participants was 53.63 ± 13.03 years, and
65% were males. Of the 100 participants, 20 (20%) developed frozen shoulder. Age (P < 0.01),
diabetes mellitus (<0.01), hypertension (P < 0.001), type of surgery (P < 0.02), and regularity
of physiotherapy follow‑up (P < 0.01) had significant association with positive LAM test on
univariate analysis. However, on multivariate logistic regression analysis, only hypertension and
physiotherapy regularity were found to have a trend toward a significant independent association
with the occurrence of frozen shoulder (P = 0.090 and 0.097, respectively). Conclusion: The
present study shows that cardiac surgery increases the risk of developing frozen shoulder during
the early postoperative period. Statistically significant correlation existed between positive LAM
test and age of the patients, presence of diabetes mellitus and hypertension, type of cardiac
surgery, and the regularity of physiotherapy follow‑up.

Received: April, 2017.

Keywords: Adhesive capsulitis, cardiac surgery, frozen shoulder, limitation in lateral rotation,
Accepted: June 2017. abduction, and medial rotation test

Introduction
T he frozen shoulder otherwise known as adhesive
capsulitis was identified as a separate clinical entity
by Duplay in 1872.[1] It is one of the most common causes
of shoulder pain and disability. The prevalence of frozen
shoulder is 2%–3% worldwide.[2] It occurs usually between
40 and 70 years of age.[3] It is a common problem in our
country in the 5th and 6th decades of life. There is a female
preponderance, but there is no predilection for race.
Frozen shoulder is a condition characterized by pain and
global restriction of movement with loss of external rotation.
It clinically categorized into three stages.
Stage I: Patients could not actively move their shoulder due to
acute pain, but full range of passive movements was possible.
Stage II: Both active and passive movements of shoulder were
restricted.
Stage III: Shoulder pain was negligible, and patients could
move their shoulder to certain extent.
Frozen shoulder can be divided into primary and secondary forms.
In the primary form, there is no associated disease or a history
of trauma or surgery of the shoulder. Secondary form may be
due to traumatic injury, surgery (including but not limited to the
shoulder), or other causes for which shoulder was immobilized.
Address for correspondence: Dr. S Saradha,
Department of Pharmacology, Chettinad Hospital and Research
Institute, Chennai, Tamil Nadu, India.
E‑mail: saradhachoks@gmail.com

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How to cite this article: Chokkalingam M, Saradha S, Navitha A, Nayar PG.

DOI: 10.4103/JCPC.JCPC_17_17 Incidence and clinical profile of patients with frozen shoulder after cardiac
surgery. J Clin Prev Cardiol 2017;6:142-6.

142 © 2017 Journal of Clinical and Preventive Cardiology | Published by Wolters Kluwer - Medknow
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Chokkalingam, et al.: Frozen shoulder after cardiac surgery
In our experience, there was a correlation between postcardiac
surgery patients and frozen shoulder. This study was designed
to check the hypothesis if cardiac surgery can predispose
frozen shoulder.
Objectives
1. To assess the incidence of frozen shoulder in patients
undergoing cardiac surgery
2. To determine the clinical profile of patients who develop
frozen shoulder after cardiac surgery.
Methods
It is a cross‑sectional, clinical observational study. This study
was done in the Cardiology Department of Chettinad Hospital
and Research Institute, Chennai, between August 2015 and
May 2016. Institutional Human Ethics Committee approval
was obtained before the study was started.
All patients above 18 years of age with no history of previous
shoulder problems and who presented for follow‑up till
3 months after cardiac surgery were included. Informed
consent was taken from all the participants. One hundred
patients fulfilling the above criteria were included in the
study. The data were collected on key variables of interest
from the respondents by face‑to‑face interview using a
standardized questionnaire by a trained physician assistant.
The questionnaire included the demographic data of the
patient, symptoms of frozen shoulder, details of comorbid
diseases such as diabetes, hypertension and dyslipidemia,
type of cardiac surgery, number of postoperative visits, and
regularity of physiotherapy follow‑up.
Respondents presenting with pain and restricted movement
of shoulder joint with positive limitation in lateral rotation,
abduction, and medial rotation (LAM) test were considered as
having frozen shoulder.
Follow‑up to physiotherapy was categorized into regular,
irregular, and no follow‑up. The study participants were
followed up for 3 months post operatively.
Statistical analysis
Data collected was expressed as actual numbers and
percentages. The statistical significance was calculated using
Mann–Whitney U‑test and Pearson’s Chi‑square test to check
the significance between the incidence of frozen shoulder
after cardiac surgery in comparison with the regularity
of physiotherapy follow‑up and associated comorbidities.
Multivariate logistic regression analysis was performed to
study the independent predictors of the development of frozen
shoulder after a cardiac surgery.
Results
The mean age of the study participants was 53.63 ± 13.03 years
and 65% were males; 40% had diabetes and 37% had
hypertension. Of the 100 participants , 20 (20%) developed
frozen shoulder [Table 1].
Journal of Clinical and Preventive Cardiology ¦ Volume 6 ¦ Issue 4 ¦ October-December 2017
Correlation between age and LAM test
Among 20 patients with positive LAM test, 5% were
in ≤30 years of age category, 5% were in 31–45 years
category, 30% were in 46–60 years category, and 60% were
in >60 years category [Table 1]. The mean age of LAM
test positive participants was 61.35 years whereas that of
LAM‑negative participants was 51.70 years [Table 2]. Thus,
advancing age was a statistically significant risk factor for the
incidence of frozen shoulder.
Correlation between cardiovascular risk
factors and LAM test
The occurrence of frozen shoulder was significantly associated
with the presence of hypertension and diabetes. Of the 37
hypertensive participants, 14 (37.8%) developed frozen shoulder
whereas only 6 (9.5%) of those without hypertension developed
this complication (P < 0.001) [Table 1]. Similarly, diabetics
also had significantly higher incidence of frozen shoulder as
compared to nondiabetics (32.5% vs. 11.7%, P < 0.001).
Type of surgery and LAM test
Out of 62 patients who underwent coronary bypass
surgery (CABG) with or without valve surgery, 18 (29.0%)
developed frozen shoulder. This was significantly higher than
in patients who underwent isolated valve surgery (2 of 35,
5.7%, P = 0.006) [Table 1].
Correlation between physiotherapy follow-up
and LAM test
In patients who had undergone regular physiotherapy, only
14% developed frozen shoulder and 86% did not develop
the frozen shoulder. In contrast, 33% of those who did not
have regular physiotherapy follow‑up developed frozen
shoulder (P = 0.013) [Table 1].
Independent predictors for postoperative
frozen shoulder
A multivariate analysis was performed to identify the independent
predictors for the risk of developing postoperative frozen shoulder
[Table 3]. Age, diabetes, hypertension, type of surgery (i.e.,
CABG or not), and regularity of the physiotherapy follow‑up
were included as independent variables. Of these risk factors,
only hypertension and physiotherapy regularity were found to
have a trend toward a significant independent association with the
occurrence of frozen shoulder (P = 0.090 and 0.097, respectively).
Discussion
Idiopathic frozen shoulder is a self‑limiting regional skeletal
problem of unknown etiology. Clinically, patients first
experience a phase of pain, progressing to a freezing stage
when glenohumeral motion is lost, followed by a thawing
phase when pain gradually subsides and most of the lost
motion returns.
The common risk factors include diabetes, old age,
postoperative period, especially after cardiac surgery and
postpacemaker implantation.
Frozen shoulder begins with an early phase of pain which
eventually leads to stiffness. This suggests that there is an
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Chokkalingam, et al.: Frozen shoulder after cardiac surgery

Table 1: Association between various parameters and LAM test

Parameters LAM test Mann–Whitney
Negative (80) Positive (20) U‑test
Count Percentage Count Percentage Z P
Sex
Male 52 65.00 13 65.00 0.000 1.000
Female 28 35.00 7 35.00
Age (years)
≤30 6 7.50 1 5.00 −2.557 0.011
31-45 17 21.25 1 5.00
46-60 34 42.50 6 30.00
>60 23 28.75 12 60.00
Diabetes
Absent 53 66.25 7 35.00 −2.539 0.011
Present 27 33.75 13 65.00
Hypertension
Absent 57 71.25 6 30.00 −3.400 0.001
Present 23 28.75 14 70.00
Dyslipidemia
Absent 73 91.25 18 90.00 −0.499 0.618
Present 7 8.75 2 10.00
Type of surgery
CABG 40 50.00 16 80.00 −2.198 0.028
MVR 20 25.00 2 10.00
AVR 9 11.25 0 0
DVR 4 5.00 0 0
CABG + AVR 2 2.50 1 5.00
CABG + MVR 2 2.50 1 5.00
Others 3 3.75 0 0
Number of visits −0.960 0.337
≤5 41 51.25 13 65.00
6-10 25 31.25 4 20.00
>10 14 17.50 3 15.00
Physiotherapy follow‑up −2.498 0.013
Regular follow‑up 61 77.22 10 50.00
Irregular follow‑up 18 22.78 9 45.00
No follow‑up 0 0 1 5.00
LAM=Limitation in Lateral rotation, abduction and medial rotation, CABG=Coronary artery bypass graft, MVR=Mitral valve replacement,
AVR=Aortic valve replacement, DVR=Double valve replacement

Table 2: Correlation between age and LAM test
LAM test (mean±SD) Independent samples t‑test
Negative Positive t P
Age 51.70±12.66 61.35±11.85 −3.086 0.003*
*P<0.05 is considered as statistically significant. SD=Standard
deviation, LAM=Lateral rotation, abduction, and medial rotation
inflammatory response which later evolves into a fibrotic
reaction.[4] Currently accepted theory is that there is an initial
active fibroblastic proliferation with subsequent transformation
of fibroblasts to myofibroblasts.[4,5] This causes an inflammatory
contracture of the shoulder, decrease in the capsular volume,
and restriction of the glenohumeral movements.[3] The role
of matrix metalloproteinases in the construction of the
extracellular matrix and in the various cytokines that control
collagen deposition has also been described.
Codman in 1934, described a diagnostic criterion comprising
of idiopathic onset, painful restriction of all glenohumeral
movements with limitation of flexion, and external rotation
with a normal radiograph.[6]
In our study, 20% of the study population developed frozen
shoulder. In a previous study from the United States, Tuten
et al. demonstrated a higher incidence (33%) of adhesive
capsulitis of the shoulder in male postcardiac surgery
patients.[7]
Age appeared to be an important risk factor for frozen shoulder
in our study as the incidence of frozen shoulder increased with
increasing age. However, there was no gender predilection.
Adhesive capsulitis or frozen shoulder is considered to be one of
the long‑term complications of diabetes. While the prevalence
of frozen shoulder is only 2% in the general population, it is

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Chokkalingam, et al.: Frozen shoulder after cardiac surgery

Table 3: Independent predictors of frozen shoulder incidence in this study

Predictor variable B SE Wald df P Exp (B) 95% CI for Exp (B)
Lower Upper
Age 0.036 0.034 1.136 1 0.287 1.037 0.970 1.107
Diabetes 0.214 0.709 0.091 1 0.762 0.807 0.201 3.238
Hypertension 1.073 0.633 2.871 1 0.090 2.925 0.845 10.122
CABG 1.168 0.933 1.568 1 0.210 3.216 0.517 20.021
Regular physiotherapy 0.980 0.591 2.748 1 0.097 2.664 0.836 8.484
Constant −3.027 2.208 1.879 1 0.170 0.006
SE=Standard error, CI=Confidence interval, CABG=Coronary artery bypass graft

reported to occur in 10%–29% of those with diabetes. Studies
have shown that adhesive capsulitis is caused by glycosylation
of the collagen within the shoulder joint triggered by the
presence of high blood sugars.[8] Adipose tissue may also have
a role to play in these patients. Adipocytes secrete proteins and
cytokines such as tumor necrosis factor alpha and interleukin‑6
resulting in overproduction of other proinflammatory cytokines,
which in turn exacerbate inflammation. Chronic inflammation,
production of free fatty acids from adipocytes, increased
expression of synovial vascular endothelial growth factor result
in persistence of inflammation and limited disease resolution.[9‑12]
Consistent with these results, we also found a significantly
higher incidence of frozen shoulder among diabetics.
Among the different types of cardiac surgeries, CABG was
associated with significantly greater risk of causing frozen
shoulder as compared to other forms of cardiac surgeries.
The underlying mechanism for this association is difficult to
explain but may be related to the differences in age and the
prevalence of other risk factors such as diabetes.
Patients in the postoperative period tend to restrict the
movement of upper limbs due to fear of pain, which tends
to precipitate the development of frozen shoulder. Therefore,
physiotherapy plays a vital role during this period. In our
study, the regularity with which the patient attends the
follow‑up sessions for physiotherapy was categorized as
regular, irregular, and no follow‑up. Regular physiotherapy
was associated with significantly lower risk of developing
frozen shoulder with 76% of LAM score negative participants
being in the regular follow‑up group.
Thus, it may be suggested that regular postoperative
physiotherapy to the upper limbs should be insisted to the
patients by the medical and paramedical personnel as it can
prevent the development of frozen shoulder in the immediate
postoperative period.
Early diagnosis with prompt referral and treatment may
prevent progression to chronic, treatment‑resistant adhesive
capsulitis. When diagnosed early, it can be treated by
application of heat to the affected area, giving nonsteroidal
anti‑inflammatory drugs and intra‑articular corticosteroid
injections. Physiotherapy and stretching exercises can widen
the range of the shoulder movement.
Limitations
• Small sample size limits our study; due to time
constraint, we had to stop enrollment.
• Long‑term outcomes were not evaluated as the patients
were followed up only for 3 months postcardiac surgery.
Conclusion
It can be concluded that cardiac surgery increases the
chances of development of frozen shoulder during the early
postoperative period. Older age, presence of diabetes and
hypertension, type of cardiac surgery, and the regularity of
physiotherapy follow‑up are important risk factors for the
development of frozen shoulder postcardiac surgery. Regular
follow‑up with continuous physiotherapy after cardiac surgery
may be helpful in reducing the incidence of frozen shoulder in
the early postoperative period.
Acknowledgment
All the authors are thankful to Chettinad Hospital and
Research Institute and Professor S Govindaraju for his
statistical assistance.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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