Frozen Shoulder

What is Frozen Shoulder?

Frozen Shoulder, also known as Adhesive Capsulitis, is a condition where the capsule, a membrane which encloses the shoulder joint, becomes thickened and tight. This process leads to stiffness and pain in your shoulder, and affects 2 to 5% of the general population.

Frozen shoulder can be classified as primary (idiopathic = cause is unknown) or secondary (typically present after shoulder injury or surgery).

Today we are talking about the primary frozen shoulder…

 

Risk Factors

Diabetes, Thyroid disease, age 40-65, female, and a previous episode of adhesive capsulitis in the contralateral arm.

 

Diagnosis

There is a gradual and progressive onset of pain and restricted active and passive ROM (range of movement) in both elevation and rotation of the shoulder. Functional activities such as reaching overhead, behind the back, or out to the side become increasingly difficult due to pain and/or stiffness.

Diagnostic Classification Criteria

Age is between 40 and 65 years old;

Pain and stiffness limit sleeping, grooming, dressing, and reaching activities;

Shoulder rotation movement (internal or external) decreases;

Imaging (x-ray) are usually normal.

 

Clinical Course 

What should you expect?

• At first, pain is the main problem. It can spread down the arm and is often worse in bed, especially if lying on the affected side, disturbing sleep.
• The pain slowly eases, but stiffness increases, becoming the main problem, before gradually resolving.
• The whole process may last from a few months to two to three years, but the pain does not last for the whole time.

How can you help yourself?

• When in pain, the emphasis is on pain relief and gentle use of your arm to ease spasm and maintain movement.
• Using your arm will not do any harm, but avoid aggravating your pain by doing too much. Take pain medication as advised. You may find hot packs helpful.
• In bed, support the arm with pillows as a reminder not to roll onto it.
• As time passes you will feel less need for pain relief.

 

Imaging

Radiographs are not routinely required, but if obtained, are typically normal with adhesive capsulitis.

 

Treatment

Conservative treatment

Intra-articular corticosteroid injections combined with physiotherapy (shoulder mobility and stretching exercises) are effective in providing short-term (4-6 weeks) pain relief and improved function. This article shows some exercises you can do.

If symptoms fail to resolve with conservative treatment, then surgery may be considered.

Surgical treatment options:

• Manipulation under anaesthesia (MUA): manipulation of the shoulder joint under general anaesthesia.
• Arthroscopic capsular release (ACR): surgical procedure to release contracted tissue.
• Hydrodilatation: injection of sterile saline solution, usually with corticosteroid, to distend the shoulder capsule.

A study from The Lancet in 2020, showed that both treatments (conservative and surgical) led to substantial improvements in shoulder pain and function. None of the treatments were clearly superior.

A study from The BMJ (British Medical Journal) in 2016, reported that treatments other than pain medication are not always needed; but steroid injections are often used to reduce inflammation and pain in the shoulder, and physiotherapy may help to diminish pain and restore movement.

A minority of people are referred to hospital with frozen shoulder, where additional options include release of the tight tissues by an injection or by keyhole surgery.

It remains unclear which options are most effective. You should discuss treatment options with your clinician, based on your needs and preferences.

Another study from JAMA (The Journal of the American Medical Association) in 2020, showed that steroid injections was associated with increased short-term  (< 12 weeks) benefits compared with other nonsurgical treatments, and its superiority appeared to last for as long as 6 months. The addiction of  a home exercise program with simple ROM (range of movement) exercises and stretches, it may be associated with added benefits. The results of this study suggest that steroid injection should be offered to people with frozen shoulder at first contact.

 

Conclusions

Frozen shoulder is a condition that can be quite debilitating and it could take over 2-3 years to recover. It is important that you find the right balance between rest and activity to prevent your shoulder from stiffening. Try to avoid the movements that are most painful and remain generally active, even if you have to limit how much you do. It remains unclear which treatment options are most effective in the long-term (conservative or surgical), but in the short-term, steroid injection is the best option; which should be accompanied by exercises to maximize the chance of recovery.

 

References:

• Shoulder Pain and Mobility Deficits: Adhesive Capsulitis, JOSPT 2013;

• Physical therapy in the management of frozen shoulder, SMJ 2017;

• Management of adults with primary frozen shoulder in secondary care (UK FROST): a multicentre, pragmatic, three-arm, superiority randomised clinical trial, The Lancet 2020;
• What is the most effective treatment for frozen shoulder? BMJ, 2016.
• Comparison of Treatments for Frozen Shoulder A Systematic Review and Meta-analysis, JAMA, 2020.