Frozen Shoulder

Background

Frozen shoulder is also called adhesive capsulitis. It is a common condition which is characterized by pain and restricted motion in the shoulder. The exact cause of the condition is unknown; however, it usually starts spontaneously without any prior accident. On occasions a frozen shoulder may develop after a small incident such as a stretch or a fall or an injury to some other part of the arm. It may occur as a complication of other shoulder surgery or even following injury or disease to a different part of the body.

It usually occurs from middle age and onward and is very common in people with diabetes and in women. It may occur at the same time as other problems within the same shoulder, an ultrasound test for example may demonstrate some bursitis or inflammation or a tear of the rotator cuff. These conditions may in fact be present; however, in the setting of a frozen shoulder they are usually of lesser importance and not the main cause of pain.

Prognosis

The natural course for this condition is for it to go away by itself after 18-24 months.
During this period of time it classically follows the following process:

• approximately 6 months of pain and restricted motion
• a further 6 months of predominantly restricted motion with less pain
• 6 months of a gradual “thawing” where pain resolves and movement improves.

At the end of this period of time most people have recovered fully; however, a small percentage has a permanent small restriction in motion.

Treatment

The first stage in treatment is to ensure that the diagnosis is correct. There are things which can mimic this condition such as arthritis and these need to be ruled out to start with. A plain Xray can assist with this.

Analgesics and anti inflammatories can be helpful to control the symptoms. No harm is done by using the arm within the limits of movement available and the condition is not worsened by use of the arm even if some pain is experienced. Control of pain however will be better by avoiding reaching or stretching frequently beyond the point of pain. Most occupations involving heavy manual tasks will not be possible.

Many forms of therapy have been tried to alleviate this condition; however, very few things are actually able to influence the natural course of frozen shoulder. In particular, physiotherapy focusing on stretching exercises should be avoided as it creates pain and does not improve movement nor speed up recovery. Physiotherapy which aims to work on shoulder blade muscles or utilizes local pain control techniques can help with pain relief.

Fig.1 Frozen shoulder

Fig. 2 Normal shoulder

The two recommended forms of treatment are as follows:

• Hydrodilatation
  
  Although the underlying cause is unknown, the structural abnormalities consistently found are of a profound inflammation of the lining of the shoulder joint and of a contracture of the surrounding capsule (see Fig.1). Hydrodilatation is an injection administered by radiologists utilizing ultrasound for guidance whereby fluid under pressure is forced into the joint in order to expand it. This fluid pressure helps to break down some scarring and contraction of the capsule. At the same time cortisone is introduced into the joint which suppresses the inflammation of the lining.
  
  The injection has approximately a 70% success rate at alleviating at least some of the pain and stiffness. The success rate is markedly higher if administered early in the disease process (within the first 3 months). The injection is often painful to have however only momentarily so. If it is partially effective but the symptoms return, it can be repeated. If successful the procedure can shorten the time frame to natural resolution of frozen shoulder.

• Surgery
  
  Should the condition be unacceptable to tolerate and hydrodilatation injections fail then a relatively minor surgical procedure can be performed which also is shown to help improve movement, reduce pain and shorten the natural course of the condition.
  
  Surgery is performed under general anaesthetic and it involves a forceful manipulation or stretch of the shoulder joint to stretch out the capsule and break down some of the scar tissue, followed by an arthroscopy of the shoulder to remove the blood which results from the stretching procedure, to remove a lot of the inflamed lining of the joint, and to divide any scarring or tight areas of capsule which could not be released through the stretch alone. The often ragged edges of the capsule which is torn as a result of the stretching procedure smoothed out and at the conclusion of the arthroscopy cortisone is injected into the joint.
  
  The procedure is performed as an overnight stay in hospital, and more prolonged admission for 2 to 3 days may be advised.
  
  Following the surgery a physiotherapy programme will be commenced so that the gains in shoulder movement can be maintained. This will need to be supplemented with a home exercise plan and this aspect is very important in maintaining and improving movement. A sling is used for only a short period of time immediately following the surgery for comfort. Shoulder pain is most often reduced from that prior to surgery however some pain is expected to persist for weeks to months following the surgery, particularly when exercising the arm.
  
  Complications of this procedure include infection, bone fracture, persistent stiffness, anaesthetic related issues or rarely damage to nerves or blood vessels passing by the shoulder. When considering this surgery these all need to be weighed up in light of the potential benefit in the knowledge that the condition in most circumstances will resolve by itself with time.

• Please contact Mr Dallalana's rooms if you require further information.