What is a frozen shoulder?
Can I do exercises for frozen shoulder?
Are frozen shoulder injections painful?
What about frozen shoulder manipulation?
Are intra-articular injections for frozen shoulder as good as surgery?
These are all questions patients have asked me over the last few months regarding frozen shoulder. In this blog I hope to answer these and a few other common queries about this painful and debilitating condition.
Frozen Shoulder
It is a painful inflammatory condition of uncertain pathogenesis or cause. It is characterised by a progressive thickening or 'fibrosis' of the lining of the shoulder joint or capsule.
Patient's Experience
Commonly patients are in their 40's or 50's and it is suggested that they are more likely to be female, although recent studies have questioned this. They are 2-4 times more likely to suffer from Diabetes Mellitus. They are more likely to suffer from thyroid and cardiac issues too.
Sometimes it can develop 'out of the blue' with no obvious cause or it can follow a 'small' or 'innocuous' injury or it can be brought on after an operation or more significant injury.
As described below the condition normally settles on its own but can take 18-24 months to do so. On occasions even longer.
Stages of Frozen Shoulder
1. Freezing Stage (0-3 months duration)
Characterised by worsening pain and development of stiffness of shoulder. Pain is often constant and severe. It interferes with sleep as a constant 'toothache like pain'. 'Jerk pain' on sudden movements of the shoulder can be sharp and excruciating.
2. Frozen Stage (3-9 months duration)
The patient can progress from having a shoulder that is very painful and stiff to one that is less painful but potentially even stiffer. Some patients will manage daily activities well others will find the stiffness inhibiting and may require treatment. External rotation (moving the arm away from the body with the elbow at the hip) and internal rotation (moving the hand up the back) are often the most restricted movements.
3. Thawing Stage (9-18 months duration)
During the final stage the shoulder is relatively pain free and the movements begin to return. The rate of improvement is often dictated by the activity the patient undertakes. Stretching exercises and physiotherapy will often speed this stage along.
Treatments
Whilst frozen shoulder is normally a self limiting condition, the duration of symptoms of an untreated frozen shoulder can drive patients to consider intervention. Treatments rarely cure the condition completely but can significantly reduce the pain experienced and shorten the duration of each stage.
Pain Killers and Time: as stated above, frozen shoulder is a self limiting condition and will normally settle on its own but can take many months to do so.
Patients can therefore wait it out with painkillers and self mobilisation as the pain eases.
Physiotherapy: I don't personally recommend physiotherapy whilst the shoulder is still very painful and inflamed ie. the freezing and early frozen stages. I find that the stretches tend to precipitate the inflammation and the shoulder stays angry and painful.
Physiotherapy during the later frozen and thawing stages when the shoulder is less inflamed however certainly improves function and recovery.
Steroid Injections: steroid injections in clinic by a GP, physio or surgeon can significantly help early symptoms of frozen shoulder. The injection is normally introduced in to the back of the shoulder and stings a little. It is normally made up of local anaesthetic and steroid. There are small (1 in 10000) risks of infection and a small risk of a flare in the pain for 2 to 3 days. The benefits can take 2 days to 2 weeks to become apparent but are not guaranteed.
In my experience these standard injections are normally more successful if treating early frozen shoulder ie within the first 3-4 months or symptoms, once the condition is more established , outcome is less predictable.
Hydrodilation: in my opinion hydrodilation is an excellent intervention. It is an X-Ray guided injection into the shoulder joint of steroid and local anaesthetic followed by normal saline (sterile salty water) to stretch up the lining of the shoulder joint or capsule.
Most patients describe it as a strange feeling of pressure in the shoulder, some uncomfortable but few describe severe pain. Many patients find they experience significant benefit within a few days.
I am currently undertaking a study to review the outcomes of this procedure in my practice. It is too early to present final results but the early indications are that most patients get excellent pain relief (70%) and are able to function more normally on a daily basis. It appears that only 2 or 3 patients out of 10 require any further treatment other than mobilisation and physio after this procedure.
I will blog the final results in due course.
If I were to suffer from frozen shoulder this would be my favoured treatment as I believe it is an excellent first treatment in most patients with frozen shoulder who are not keen on the wait and watch approach.
Surgery:
In my opinion, apart for a few exceptions, discussed below, surgery should only be considered after a trial of hydrodilation. This is because hydrodilation will give the majority of patients a significant reduction in their pain and function with lower risks of complications when compared to surgery.
Manipulation Under Anaesthetic (MUA): this procedure involves being put to sleep under general anaesthetic so no pain is felt. The surgeon will assess the true range of motion or stiffness whilst the patient is asleep and pain free. They will then carefully manipulate the shoulder into external rotation, side ways elevation (abduction), forward elevation (flexion) and internal rotation. This results in the tearing of the joint lining or capsule and the thickened scarred tissues.
The surgeon will often regain full movement of the shoulder during the surgery. Regular pain killers and physiotherapy are essential to maintain movements although due to discomfort and muscle spasm the patient will rarely keep all of the movement in the early post operative days.
There are small risks of fracture, dislocation and tendon injury.
Patients normally experience a dramatic improvement in pain levels and in my experience patients can maintain 60-75% of their normal range after this procedure at about 6-8 weeks.
Perseverance with physio will normally result in a near normal shoulder function between 6-12 months.
Arthroscopic Capsular Release and MUA: this is a similar procedure to that described above. The slight difference is that a camera is installed into the shoulder joint from behind through a 1cm incision and an instrument from the front of the shoulder. Some of the thickened capsule is then removed from the shoulder (rotator interval) prior to the MUA being undertaken. This potentially reduces the forces required to tear the shoulder capsule, hence reducing possible risks of fracture but it does have the very small risks of an infection as instruments are placed into the joint.
There is not an agreed consensus in research whether one procedure is better than the other however it is generally agreed that the outcomes of pain relief and return to function (work and hobbies) are similar over a period of 18-24 months.
I believe a capsular release is most indicated in patients with a more chronic picture (symptoms >18 months), when conservative treatments have failed, in patients with frozen shoulder secondary to a shoulder fracture or significant injury and in diabetic patients who often have a more unpredictable recovery and can develop marked thickening of the shoulder capsule.