Frozen Shoulder (Adhesive Capsulitis)
What is frozen shoulder?
Frozen shoulder is a condition of unknown cause which leads to pain and stiffness in the shoulder. It is generally self-limiting and in time predominantly resolves. The condition is the development of an inflamed articular capsule, with associated pain and stiffness. Whilst the cause is unknown, it is more common in diabetic patients and those who have suffered a heart attack or had breast cancer treatment. It can occur after trauma. It is a condition that runs through 3 to 4 main stages and is associated with intense pain and stiffness of the shoulder (in particular the glenohumeral joint).
What are the stages of frozen shoulder?
Traditionally it has been known as 3 stages, although at Glenelg Orthopaedics we consider it to be 4 stages.
1. Painful Phase
Initially the patient will present with severe pain. The pain will be poorly localised but generally is felt in the front of the shoulder. It may start after a knock, but some people notice it on the first occasion when reaching for something and the pain can become quite intense. Often the pain is associated with deep seeded discomfort and often there will be a “neurogenic element” to it, where the patient will feel teary or even depressed. Initially the movement of the shoulder will still be good, and the initial treating doctor may make the diagnosis of bursitis. Ultrasounds undertaken at that time may demonstrate bursitis, and this is a common finding even in normal patients. However the patient will not respond to a steroid or cortisone injection into the shoulder.
2. Painful and Stiff
The second phase is when the shoulder starts becoming stiff and at this stage the patient is “beside” themselves and having trouble undertaking axillary (armpit) care. Reaching for anything causes discomfort and they have severe pain at night.
3. Stiff Phase
Eventually, the pain starts to settle but the shoulder remains stiff. During this stage, the patient is relieved that the pain is settling and feels that they are starting to make progress or heal. This is the phase that best responds to treatment but by this stage, as the pain starts to settle, patients feel that they no longer require treatment as they can see the light at the end of the tunnel.
4. Thawing Phase
Finally, the fourth phase is the recovery phase, when everything settles. Although most patients are left with slight loss of motion, they are significantly better and for all intents and purposes they feel they have fully recovered.
Is it a reoccurring condition?
Unfortunately, at a later stage of life, it is likely that the patient may develop frozen shoulder in the other shoulder. The good news is that it is extremely rare for a patient to develop frozen shoulder back in the same shoulder once it has settled.
Diagnosing a frozen shoulder
In the vast majority of cases, the diagnosis is made from the history and a good clinical examination. The condition usually occurs in the 30 to 55 year age group, and is rare in a younger person. In an older patient, one must exclude osteoarthritis as a cause of the stiffness and pain. The most important investigation is an x-ray which will help to exclude any AC joint arthritis or other arthritis conditions.
On occasions, an MRI scan may be worthwhile to exclude other pathology and also can suggest adhesive capsulitis, but is not diagnostic in that it does not prove the condition.
How is Frozen Shoulder Treated?
Generally, the treatment is reassurance. If the patient can ride out the condition, it will resolve so that they are happy with the outcome. However, the patient is often desperate to try something and as such, unfortunately the best time to have treatment is later in the condition, from stage 3 onwards. Consequently, as opposed to what a patient may believe, the longer one waits for treatment, the better the outcome.
Physiotherapy is worth trying, although there is some suggestion that this may make the condition worse in the initial stages. In general, we believe that some gentle physiotherapy and hydrotherapy may help make the condition more tolerable. If, however, a patient is feeling things are deteriorating with physiotherapy this should always be stopped.
A “hydrodilatation” or injection of steroid is worth trying and can be very successful. This is an injection of cortisone to try to stretch and settle the inflamed capsule, and is performed by a radiology team. It can be very successful, but the best results once again are later in the time frame (aiming for phase 3). It does carry a very small risk of infection but is usually very safe.
Treatment options also include such things as manipulation and cortisone injections. This involves a general anaesthetic procedure and the actual shoulder manipulated to release any scar tissue, with a dose of steroid being injected into the shoulder. This traditionally has had very good results but does run the risk of a fracture or break of the shoulder. Consequently, it is more common now that a surgical procedure is undertaken in those rare cases that require surgery.
This is undertaken through an arthroscopic approach where a telescope is inserted into the shoulder and scar tissue is released under surgical guidance. That being the case, the longer one waits to undergo surgery or manipulation, the better the results. As stated above, usually the best time for the patient to have a good result from the surgery is when they have reached stage 3. By that stage most patients do not feel they want to go down this path and accept the risks. As such, we believe surgical procedures such as manipulation or arthroscopic release should be avoided.
In summary, frozen shoulder is a common condition however the main aspect of treatment is time for the condition to resolve. In the vast majority of patients, the patient will do very well with some gentle physiotherapy, time, reassurance and hydrotherapy.
Get a diagnosis, treatment advice, and regular checkups from Dr Gavin Nimon, your local shoulder specialist.
Glenelg Orthopaedics – Providing Quality Orthopaedic Care