FROZEN SHOULDER

The shoulder joint is a shallow ball and socket joint which allows for great movement but comes at the risk of shoulder instability.  The joint capsule, ligaments and rotator cuff muscles are crucial in maintaining the stability but need to be elastic and flexible to allow movement to occur.

Frozen shoulder or adhesive capsulitis is a common condition which causes pain and loss of movement in the shoulder, often for a substantial period of time.  This can result from an injury but often occurs with no history of injury.  It can also occur following surgery.

The exact underlying cause of frozen shoulder is unknown but the capsule of the shoulder joint becomes inflamed. Some groups of people are more at risk of frozen shoulder such as people with diabetes, thyroid disease, heart disease and Parkinson’s disease.

THE CLINICAL PICTURE

Initially when the shoulder becomes inflamed the pain starts.  This may be noticed as a gradual onset of soreness but is often noticed as a distinct pain when the shoulder stretched or pushed. After that the pain gradually becomes worse.  It is relatively constant in nature and it is usually worse at night.  With time the condition passes through 4 phases.

Freezing Stage:

Initially the pain is present but movement in the shoulder is relatively normal. This is the stage of progressive inflammation with the capsule becoming increasingly inflamed.  The shoulder becomes stiffer and more painful.  The typical duration is 6 weeks to 9 months.

Frozen Stage:

The inflammation in the shoulder starts to settle so that the shoulder pain starts to improve but the shoulder remains stiff. The duration is usually 4 to 9 months.

Thawing Stage:

With time, the scarring gradually stretches and the full range of motion eventually returns.  The usual time course through all four stages is between 9 months and 2 years depending on the severity.  

TREATMENT

Initial treatment is focused on treating the pain.  Paracetamol and anti-inflammatories such as ibuprofen or diclofenac taken regularly can be effective in managing the pain. Physiotherapy is useful in helping maintaining the movement but can increase the pain on occasion.

Cortisone injections into the shoulder joint can be very effective in relieving the pain in the shoulder.  Cortisone is a powerful anti-inflammatory medication which helps settle the inflammation and reduces the scarring of the shoulder capsule.  The constant ache of the inflammation eases over 1-2 weeks but there is often some residual pain at the extremes of movement when the capsule is tight.  Once the inflammation starts to subside, the swelling of the capsule gradually decreases and the movement improves.  

SURGERY

When the capsule is very tight, then release of the capsule may be necessary. Surgical release of the capsule is performed as a keyhole procedure and can be very effective to improve the range of motion and pain.  There are risks with all surgical procedures so surgery is not usually the first treatment choice.  Surgery is helpful in patients with very restricted movement, bilateral disease, and in those who have not improved with injections.