Frozen Shoulder – Adhesive Capsulitis

Have you got a frozen shoulder (adhesive capsulitis?)

Frozen Shoulder Causes and Treatment

Have you’ve been experiencing sudden, sharp, shocks of pain in your shoulder that bring tears to your eyes?

Perhaps you’ve noticed that your shoulder is becoming very stiff, and you’re struggling to get dressed, and that your pain is waking you from sleep?

Is this the worst pain you’ve ever experienced in your life?

You may have a frozen shoulder and I can help you stop the pain

What is a frozen shoulder (adhesive capsulitis?)

Frozen shoulder can be an exquisitely painful condition.  Simply put, it’s inflammatory and scarring process that affects the capsule (which is the connective tissue structure that encases the shoulder joint). It’s a common condition, and it’s thought that as many as one in twenty people might experience frozen shoulder at some point in their lifetime.

What causes frozen shoulder?

Why frozen shoulder happens to some people, and not others, is still somewhat unknown. But we do know it’s more like to occur:

  • If you are aged between 40-65 years

  • If you have diabetes or another metabolic condition

  • If you’ve had surgery to your shoulder

  • If you are a woman and are peri-menopausal

  • If you’ve had trauma to the surgery

  • If you have problems with the rotator cuff tendons

  • If your shoulder has been very immobile (e.g. after a stroke)

Many of the patients I meet who have a frozen shoulder, are going through some hormonal shifts which may contribute to their condition.  They might be experiencing a drop in oestrogen levels as they approach and continue into menopause. Sometimes stressful life changes (such as divorce, bereavement, or negotiating the ups and downs of a teenager in the family) can produce an increase in the stress hormone, cortisol.

What’s actually happening when a shoulder becomes frozen?

Here comes the techy bit.

It’s believed that there’s a process of inflammation and fibrosis (scarring) of the capsule, which is brought about by the action of inflammation inducing cytokines and growth factors released by cells in our immune system.

It’s generally recognised that there are three stages in the story of a frozen shoulder.

The stages of frozen shoulder:

The first stage is the “freezing” stage – this is a painful stage that occurs as the shoulder begins to become very stiff due to inflammation and thickening of the joint capsule. Characteristically, night-times are particularly painful, and this stiffness significantly limits the range of motion in the shoulder.

The second stage is the “frozen” stage. The shoulder remains stiff, but thankfully, the pain may begin to ease during this stage.

The third and final stage is the “thawing” stage, and during this time the ability for you to be able to move the shoulder improves, and often returns to normal.

The amount of time spent in any of these phases varies from person to person. If you do a search on the internet, you’ll probably have read that two years is a typical length of time for a frozen shoulder to recover. Unfortunately there have been studies describing much lengthier recovery times, even up to five years, which is too long to put up with that amount of pain and disability.

You might also have read that it’s not uncommon for it to affect both shoulders. But all is not lost, and there are some really simple things that can be done to improve the situation.

What the symptoms of a frozen shoulder?

You might be wondering if you actually do have a frozen shoulder and how we can differentiate it from other conditions that may give you similar shoulder symptoms?

Most people will first notice that they start to have pain and stiffness, and this is often much worse at night-time. Many people put up with pain for a long time and will only consult a doctor or a physio once their shoulder starts to become less mobile.

When the shoulder starts to become stiffer, one of the tell-tale signs that it might be frozen shoulder, is that the internal and external rotation of the shoulder becomes restricted. That means, you might find it very difficult to do put on your bra with your hands behind your back, or to swing your arm outward in a forearm tennis shot.

How to Diagnose Frozen Shoulder

Frozen shoulder is a clinical diagnosis, which means that we come to a diagnostic conclusion based on the symptoms you describe and the physical examination – particularly the restricted range of rotation movement.

Sometimes, I recommend that we carry out some imaging of the shoulder (e.g. an MRI or ultrasound scan) to rule out any other causes for your pain, or contributing issues within the shoulder.

What’s the treatment for frozen shoulder?

The good news is, there’s lots that can help when you have a frozen shoulder.

In the early or “freezing” stage of frozen shoulder, pain is often the biggest issue, and if your movement is only a little limited, you might not yet know that you have a frozen shoulder.

In this early stage, painkillers (in the form of anti-inflammatory medications such as ibuprofen) can help. It’s important to keep moving the shoulder (i.e. don’t shy away from using it), but it’s not helpful to push on through with activities that aggravate it, e.g. playing tennis.

Patients have told me that physiotherapy has often made their symptoms worse. This is understandable, given the degree of inflammation. I recommend delaying physical therapy until after the injection, so that the pain is more manageable.

How to Cure Frozen Shoulder Quickly

I recommend a“hydro-dilation” to reduce pain quickly and improve the range of movement in your shoulder. It’s also called a “hydro-distension” or a “high volume” shoulder injection.

This injection is carried out with ultrasound guidance. The injection contains local anaesthetic, anti-inflammatory corticosteroid, and saline. It gently stretches the lining of the shoulder, helping to free up any restrictions. The local anaesthetic means the process is very comfortable, and the steroid helps to combat inflammation and pain.

Many patients say to me that the effects of the injection are miraculous and can get rid of their pain within days. The biggest game-changer is that they can sleep through the night. Recovery of shoulder movement takes longer – sometimes weeks.

To get the best benefit from this frozen shoulder treatment, it’s important to work with your physiotherapist or osteopath to encourage an improved range of movement. If you don’t get the range of movement and function that you need, we have the option of repeating the injection six weeks after the first.

Rarely, for some patients, the restriction in the shoulder is still problematic after the second injection, and then they may wish to consider surgery. I do not recommend repeated injections into the shoulder joint as this may cause damage to the tissues.

Contact Your Shoulder to discuss the frozen shoulder treatments available to you.

Frozen shoulder surgery (arthroscopic capsular release)

Whilst frozen shoulder will eventually improve slowly over time for most patients, this can take years. If you’re experiencing a frozen shoulder, and you’ve tried physiotherapy and injection treatment and are still not getting better, it may be time to consider surgery, aka an “arthroscopic capsular release” operation. Most patients tend to be in the second stage aka the “frozen” stage of frozen shoulder when they undergo the operation.

In the past, all we had to offer patients for their stiff shoulder was an “MUA” – manipulation under anaesthesia. This is a procedure carried out under a general anaesthetic, and it involves forcefully pulling the shoulder in different directions, to free up the stuck down capsule. This procedure has several potential complications (including damage to the joint and nerves), and thankfully we are now able to offer patients a more elegant solution – keyhole surgery.  The aim of the surgery is to release the scarred capsule that’s limiting the shoulder movement, so you can move your arm freely, and with less pain.

Most frozen shoulder surgery can be carried out as a day-case procedure. On the day of the surgery, you’ll have a light general anaesthetic (so you’ll be fully asleep and won’t feel anything), and you’ll also have a nerve block too. When you wake up, your shoulder and arm will be numb for a few hours, so that you will be comfortable after the operation.

You will have two or three very small incisions around your shoulder, so that I can place a camera into the joint, and use what’s called a radiofrequency probe to cut through the tight and constricted capsule that is restricting your shoulder.  On the day of surgery, you’ll be shown some exercises to do, and you’ll be encouraged to move your shoulder as much as possible, within your comfort levels.

After the surgery your shoulder and arm will be numb for several hours, and you’ll be given a sling for support, just for a couple of days or so. It’s natural to have some discomfort after surgery, but you’ll leave hospital with really good painkillers to minimise any pain.

At night I recommend that you try either laying on the opposite shoulder or on your back, and try putting a pillow under your surgery arm to support it and discourage rolling over onto that side.

It’s super important to keep your shoulder mobile after the shoulder, and not try to guard against movement. In fact, the patients who do best, are really proactive with their rehab, and I recommend that you see your physiotherapist within five to seven days after surgery.

The good news is, recovery after the surgery is fairly swift, and most people are feeling very much more comfortable by six weeks, and often it’s possible to get back to work within the 2 weeks, and often patients return to work after just one week.  At three months, you should be back to normal.

Most patients are able to drive a week or so after the operation, as long as you have a good range of movement and can operate a vehicle safely.

If you’re a swimmer, you could expect to be getting back into the pool and doing some breaststroke swimming at around 4 weeks post op. If contact sports are more your thing, there’s no reason other than pain, to prevent your returning to your sport. Once you’re comfortable and you can move well, you’re good to go.

Thankfully, complications or poor outcomes after this kind of surgery are rare.

The risk of infections or damage to nerves and blood vessels is less than 1%.

At around five weeks, some patients may experience the shoulder becoming stiff and painful again, and if this happens, a final hydrodilation injection usually sorts the problem out.

In my practice, 85% of patients make an excellent recovery with no pain and good range of movement. 10% have a good outcome in that the pain has gone, but the movement may become restricted again after surgery. In this case a further injection might be reuired around 6 weeks after surgery. 5% of patients may have ongoing stiffness or pain, and might need a second operation or more time, for the shoulder to completely recover.

You may be wondering what are the chances of your frozen shoulder returning after surgery? It’s very unusual for a frozen shoulder to return to the same shoulder once you’ve had surgery, but it is possible for the other shoulder to become affected – this happens in approximately 20% of patients.

Most patients have an excellent outcome; if you have diabetes or a frozen shoulder as a result of trauma, such as a fracture, it can be harder to recover your full range of movement.

I very much believe in supporting you through every stage in your journey. Frozen shoulder is a life-changing condition, but fortunately, it’s something we can treat relatively swiftly, and with very little risk.

As I often say to patients, no two shoulders are the same, but if you’ve tried lots of rehab and injections, and you’re struggling to be active in the way you’d like to be, it’s maybe time to consider surgery.

Post surgery FAQ

Don’t rush back to work; try to take off at least a week.

It’s important to use the keyboard with your forearms supported on the desk. Wait till you’re comfortable and don’t overdo it?

Yes, unless you’ve had surgery for a frozen shoulder, or shoulder impingement surgery – in which case, you can take it in and out, as comfort allows.

Avoid baths until the dressings have been removed – typically at 10 days. Your wounds will have waterproof dressings on, so it’s ok to take a shower. It’s really important to keep your arm pits clean – so have a good scrub with a flannel!

Make sure that your hand is above the level of your elbow, so that your arm is completely relaxed in the sling

For the first three to four days, don’t wait for the pain to kick in, take them regularly (even if you’re not feeling pain – we want to keep it at bay).

Yes.

Lying flat can be painful, so try propping yourself up on several pillows.

You can sit on a stationary bike straight away (as long as you keep your arm in your sling). You’ll be given more detailed instructions about other activities, when you are seen in clinic.

My secretary will arrange a follow up appointment approximately 10 days after surgery. At this appointment, I’ll remove your dressings, and check that the wound is OK. If you’ve had surgery for a fracture or joint replacement, we may need take an X-ray.

Ms Susan Alexander is a senior orthopaedic surgeon and is recognised by all the UK’s major insurers.

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