Anatomy
Frozen shoulder (Adhesive capsulitis) is a common condition occurring mainly in women between 40 and 70 years old. The lining of the shoulder becomes thickened and contracts, causing pain, loss of motion or stiffness. The causes of a frozen shoulder are unknown, however patients with a history of diabetes, thyroid and other diseases have a greater risk of developing a frozen shoulder.
A frozen shoulder occurs in three phases:
- Freezing Phase: This is usually signified by pain on activity, rest and at night. Restriction of movement is also noted. This may last from a few weeks to a few months.
- Frozen Phase: The shoulder progressively stiffens and pain begins to decline. This may last from a few months to nearly a year.
- Thawing Phase: The shoulder begins to improve and movement returns to normal over a period of 6 to 24 months.
Whilst this condition does resolve spontaneously, it is often very disabling because of severe pain and the loss of movement. Not all cases resolve within the expected time frame, and the condition may go on for longer than the 24 months that is often stated.
Non-operative Treatment
Unfortunately, the pain is of a nature that only strong analgesics and sleeping tablets will control it. This can cause problems because of dependency on the medication.
A regime based on regular Paracetamol, two tablets four times a day, and an anti-inflammatory drug is often recommended as a baseline therapy. Adding a stronger painkiller for severe pain, and a hypnotic to help induce sleep on at least some nights of the week may be sufficient to control the symptoms and allow for a tolerable lifestyle whilst this condition settles.
Maintaining movement of the shoulder is difficult - forcing it is often very painful, so physiotherapy does not usually help. Similarly, cortisone injections have a limited lifespan, and are again not particularly helpful.
Operative Treatment
Manipulation Under Anaesthesia; Shoulder Arthroscopy
Surgery is aimed at stretching or releasing the contracted joint capsule of the shoulder. Manipulation of the shoulder joint under a general anaesthetic may help. Recently, an arthroscopy of the shoulder has shown promise in relieving symptoms. This procedure involves a capsular release and excision of the rotator interval in the joint. This procedure has the benefit of increasing the range of movement in the shoulder and speeding recovery. It is a reasonable adjunct to conservative measures if pain and stiffness are disabling over a long period of time. Both procedures are usually performed as a day surgery case.
Post-operative Course
Recovery from arthroscopic shoulder surgery varies and especially so in the treatment of a frozen shoulder. Exercises to maintain the motion that was achieved in the surgery are encouraged. As a guide, a six week to three month recovery period can be expected.
Risks/Complications
The pain and shoulder stiffness associated with a frozen shoulder may not be completely relieved following manipulation or surgery in a small number of cases. In this instance it may be necessary to have repeat surgery.
Risks associated with arthroscopic shoulder surgery include:
Practice Perspective
It is important to recognise that the majority of people whose shoulder is labelled as a “frozen shoulder” in fact have an impingement syndrome, with a range of movement loss due to pain. Impingement syndrome can be treated very differently from the true frozen shoulder, responding well to standard treatment for rotator cuff impingement.