Frozen Shoulder (Adhesive Capsulitis)
Knowledge that empowers
What is it?
Frozen shoulder is the common name for a condition known to medical professionals as adhesive capsulitis.
In frozen shoulder, the soft tissue capsule that encloses the ball and socket joint of the shoulder, known as the glenohumeral joint, becomes inflamed, causing pain and development of thick scar tissue which causes progressive loss of movement in the shoulder.
In most cases it will almost fully resolve but this can take a significant period of time (up to 1-2 years on average, occasionally longer). Despite frozen shoulder being a fairly common and well observed condition, it is not exactly clear what causes or triggers this inflammatory process to occur.
Who is affected?
Frozen shoulder is often insidious, meaning that the disease process occurs without injury or known cause.
It is more common in those between the ages of 40 and 60 and is more common among people with diabetes, pre-diabetes and some other medical conditions such as thyroid disease.
Women are somewhat more likely to be affected, and this is thought to be, in some part, due to hormonal changes that occur around the time of menopause. Also the left shoulder is involved more commonly than the right.
Despite most cases of frozen shoulder occurring without a history of injury, it can also develop after a shoulder injury or after immobilisation of the arm in a sling following injury or surgery.
What are the symptoms?
Frozen shoulder usually begins with pain around the shoulder or upper arm which may be worse at night.
Over several weeks or months the pain may increase and then you may notice a loss of movement in the shoulder. It may become difficult to move your arm above your head, to reach out or behind your back. While adhesive capsulitis is known to be self-limiting, the duration of symptoms can last up to a few years.
Stage One: Freezing, painful stage
The first symptom of frozen shoulder is usually pain or an aching sensation felt in the shoulder or upper arm. For some, the pain can be severe initially, and this may last for several months. An injection of corticosteroid into the shoulder joint has been shown to be helpful in managing pain during this phase.
During this phase, continue daily activities as comfort allows, but avoid aggressive stretching, exercise or activities that significantly aggravate your pain. Your physiotherapist may be able to provide some education and advice about how to manage your frozen shoulder but aggressive stretching and mobilisation is not recommended in this phase.
Stage Two: Frozen stage
During this phase the pain will gradually improve, but your shoulder will still be stiff and have limited movement (‘freezing’). This phase can last up to 12 months. Once the pain has settled physiotherapy may be of benefit to help gradually stretch and mobilise the shoulder to help restore movement.
It can be difficult to know whether your frozen shoulder is progressing in this stage, therefore it is important to check in periodically with your physiotherapist or specialist to measure the range of motion in your shoulder.
Stage Three: Thawing stage
In this stage, pain is almost completely gone and the shoulder starts to ‘thaw out’, with movement gradually returning over a period of 1-3 years. Sometimes it can take up to three years to recover fully. In some patients it may take longer, especially diabetics.
At this stage it’s important to see a physiotherapist for exercises that will help you get full movement back, strengthen your shoulder muscles and return to physical activity that may not have previously been possible.
How is the diagnosis made?
Frozen shoulder is often quite difficult for doctors and other health professionals to diagnose in its early stages.
This is because the hallmark sign of frozen shoulder, being restricted range of motion in all directions, can be very subtle in the early inflammatory phase.
Frozen shoulder is typically a clinical diagnosis. It is suspected after taking a clinical history, and is then made by excluding other conditions that are likely to cause shoulder pain and restricted range of motion.
In Australia, the routine imaging requested for those presenting to a general practitioner with shoulder pain typically includes an x-ray and an ultrasound, both of which are not accurate tests to confirm the diagnosis of frozen shoulder. The x-ray can, however, help exclude other causes of stiffness, such as arthritis, in the shoulder.
An experienced radiologist or shoulder specialist may be able to identify signs of frozen shoulder on an MRI scan, although this is not always necessary.
What is the prognosis?
The time frames in each stage vary for individual patients and, unfortunately, there is no way to predict how long each stage will last.
Some patients experience shorter recovery times, and some patients experience longer recovery times. Treatment techniques for frozen shoulder are often directed by whether there is more pain than stiffness, or more stiffness than pain.
While a frozen shoulder can be painful and slow to resolve, the good news is that, in the majority of cases, it will almost fully resolve over time. It is also unlikely to recur in the same shoulder, although around 30% of people may experience a frozen shoulder on the opposite side at some stage, more frequently diabetics.
Non surgical treatment
Some cases of frozen shoulder eventually recover without the need for surgery. However in persistent cases, surgery may be required. Treatment options for frozen shoulder are listed below:
Because most frozen shoulders eventually resolve, and the pain can be tolerated, most patients opt not to pursue any form of treatment.
There is good research evidence that an injection of corticosteroid (anti-inflammatory) into the glenohumeral joint (shoulder) can be beneficial treatment for managing pain in the early inflammatory stage of frozen shoulder. This may help with pain, but it won’t improve the shoulder stiffness. The injection can be performed by a medical practitioner, and preferably under imaging-guidance by a radiologist to ensure it goes into the glenohumeral (shoulder) joint.
The effect may last several weeks or several months. If pain returns, the injection can usually be repeated one or two more times.
Some people with diabetes can experience poorly controlled blood sugar levels for several days or weeks following a corticosteroid injection and more regular monitoring of blood sugar levels is recommended.
Once the pain has settled, and pain is not disturbing your sleep your physiotherapist can guide you in gradual stretching, mobilisation and strengthening of your shoulder.
During the early painful stage, aggressive shoulder stretching and mobilisation is usually not tolerated, however your physiotherapist, doctor or shoulder specialist can provide education and advice on managing pain and activity.
Hydrodilation is a technique where a small catheter is inserted into the shoulder joint under imaging guidance. Under aseptic conditions, the shoulder is progressively filled with fluid, often consisting of local anaesthetic, cortisone and sterile saline to gently expand and stretch the soft tissue capsule of the shoulder joint.
Once this procedure has been completed, it is critical to commence a program of stretches for the shoulder to regain as much range of motion as possible.
Arthroscopic capsular release
If your shoulder movement is not improving in an appropriate time-frame, an arthroscopic release of the shoulder may be offered.
Surgical release of the shoulder joint capsule with ‘keyhole’ surgery can be performed to release the thick and tight shoulder capsule. A brief stay in hospital for 2 days may be required to ensure that you are kept comfortable to be able to participate in regular range of motion exercises for the shoulder.
Associate Professor Raniga’s experienced anaesthetic team may also make use of a local anaesthetic pump that stays in shoulder while you are in hospital. This pump is often very effective in controlling pain after surgery and allows you to complete range of motion exercises in a comfortable and supportive environment.
Physiotherapy is critical after this procedure to regain range of motion, provide advice on suitable activities of daily life and return to work. You will likely need to complete your exercises multiple times each day after this surgery. Given that it is possible for stiffness to return following surgery, it is very important that you are able to devote plenty of time each day towards your rehabilitation. If you have a busy schedule, this can mean that return to work is not wise in the first few weeks after surgery.