Frozen Shoulder
Although frozen shoulder is fairly common, ongoing research keeps challenging and expanding on what we know about this painful and debilitating condition. The name was started in 1934 by Codman who described the disorder as “difficult to define, difficult to treat and difficult to explain” which in many ways, is still true today. Some of the key features is pain, sleep deprivation, anxiety and restricted movement in the shoulder leading to disability that can hugely impact daily activities and quality of life. It can take anything between one month to three and a half years to resolve which can make it a burdensome injury. One of the most widespread misconceptions is that this is a self-limiting condition that will eventually resolve or “thaw” without the need for supervised treatment. Quite the opposite, seeking early treatment can help with improving pain and restoring range of motion and function.
There are two types of frozen shoulders, the primary type being more of a mystery since it starts by itself without any clear cause or injury. Secondary frozen shoulder can be associated with an event or disease such as a rotator cuff tear or diabetes. Essentially what happens is that the capsule surrounding the ball and socket joint of the shoulder becomes inflamed and stiff, making it painful to move the arm. The capsule tightens up in some areas more than others making it harder to do certain movements such as putting on your coat or brushing your hair. Eventually, the pain reduces as the inflammation in the capsule settles down and reaches a plateau, leaving behind a stiff shoulder which will gradually loosen up again.
Risk factors
- Frozen shoulder mostly affects people between the ages of 40 and 60
- More women than men are affected
- Traumatic injuries such as falls, surgery or rotator cuff tears
- Immobilisation after surgery
- Conditions such as Dupuytren disease, hypothyroidism or hyperthyroidism, Cardiovascular disease, Stroke and Parkinson’s Disease
- Diabetes – Studies show that people with diabetes are 10-36% more likely to get frozen shoulder
- Menopause
- 6% to 17% of patients within 5 years get frozen shoulder on the other side too.
Diagnosis
As with many musculoskeletal injuries, a thorough history taking would give many clues to the diagnosis followed by a physical examination of the shoulder. This would usually be enough but sometimes a consultant or GP may refer for imaging such as an X-Ray or MRI to confirm or rule out any other conditions such as rotator cuff tears or osteoarthritis.
Treatment of frozen shoulder
The belief that the shoulder would make a full recovery without supervised treatment has circulated the industry for a surprisingly long time considering it has very low-quality evidence to back it up. This is due to the continued citation of these secondary sources in articles, websites and books, despite stronger contrary evidence and has led to delayed treatment. Consequently, this results in worse outcomes as evidence suggest that more gains will be made in the early phase of the disease, before a plateau is reached. This is likely due to more thickening and adhesions forming in the capsule as the disease progresses.
Treatment goals of frozen shoulder should be discussed as part of a shared decision-making process and would determine the best treatment approach for the individual. Most often, a course of physiotherapy would be the starting point to try and reduce the pain and improve the movement in the shoulder conservatively. If it is too painful or no progress can be made the following options are available:
- Manipulation under anesthesia (MUA)
- Arthroscopic capsular release (ACR)
- Distension arthrogram or hydrodilatation
- Corticosteroid injection and physiotherapy – usually to supplement any of the above interventions
Hydrodilatation is one of the more popular treatment approaches where the shoulder is injected with saline and local anesthesia under pressure to stretch the capsule. This is usually performed by an interventional radiologist under ultrasound guidance. This treatment provides a window period where physiotherapy can be very effective in improving range and function in the shoulder.
It’s important to create awareness that the wait-and-see approach is not recommended anymore and that starting supervised treatment earlier can help with the guided management of this condition and potentially reduce the duration of this painful and frustrating condition.
- Victoria Ryan, Hazel Brown, Catherine J. Minns Lowe, Jeremy S. Lewis, The pathophysiology associated with primary (idiopathic) frozen shoulder: A systematic review, BMC Musculoskeletal Disorders vol. 17, no. 340, 2016
- C.K. Wong, W.N. Levine, K. Deo, R.S. Kesting, E.A. Mercer, G.A. Schramc, B.L. Strang, Natural history of frozen shoulder: fact or fiction? Physiotherapy vol. 103, 40–47, 2017