The name ‘frozen shoulder’ was first coined in 1934 by a surgeon called Codman. Frozen shoulder is a common, painful and disabling condition. It affects 2-5% of patients who consult their doctor complaining of a shoulder problem and is more common in patients suffering from diabetes with up to a third of those patients being affected. Frozen shoulder is more common in women and most often occurs between the ages of 40 to 60 years.
In a ‘Frozen Shoulder’ the lining or capsule of the shoulder joint physically thickens due to overproduction of scar tissue and in some ways a better term for the condition would be ‘Contracted Shoulder’.
In the majority of patients the cause of the frozen shoulder is unknown although it can be caused by a fall, trauma, fracture, or recent surgery.
Frozen shoulder is a condition that is characterised by three distinct phases: the 'freezing' phase, 'frozen' phase and 'thawing' phase.
The ‘freezing’ phase is a very painful phase which lasts on average 2 to 9 months. It often starts insidiously with shoulder pain which can interfere with sleep and is often worse with movement. In this phase the pain is more prominent than the stiffness.
The patient will then gradually enter the 'frozen' phase which is characterised by stiffness and often lasts between 3 to 12 months. The shoulder pain begins to improve but the shoulder becomes progressively stiffer. It is this stiffness which becomes the patient's main problem preventing them moving their shoulder and the stiffness is more prominent than the pain.
Classically in frozen shoulder if you place the patient's elbow at their side patients are unable to rotate the arm outwards as much as their normal arm. This is called a lack of external rotation of the shoulder. In frozen shoulder all movements of the shoulder are restricted but it is this lack of external rotation which is the most obvious.
Eventually the patient enters the 'thawing' or recovery phase which can last between 5 and 26 months. The movement in the shoulder gradually returns and most patients achieve a full recovery although a small proportion of patients experience some residual symptoms.
Hence, it can take on average 2 1/2 years (12-42 months) for the condition to resolve during which time the patient can be significantly debilitated by pain and stiffness in the shoulder limiting their ability to perform their daily activities, work and recreation. There is some evidence that those patients who have very severe symptoms at the start often go on to have a more protracted recovery and some patients do not regain their full range of movement. Patients who suffer from diabetes or who have developed a frozen shoulder after a trauma or surgery often take longer to recover.
Frozen shoulder is associated with a number of other conditions including: diabetes, thyroid disease, Dupuytren's disease in the hand, Parkinson's, stroke, cardiac surgery or following a heart attack.
The diagnosis of frozen shoulder is usually made on the clinical history and clinical examination. It is important to have an x-ray of the shoulder to exclude other causes of pain and stiffness such as arthritis, calcific tendinitis, avascular necrosis or even dislocation. An x–ray which is reported as normal will exclude both arthritis and dislocation and therefore help confirm the correct diagnosis of frozen shoulder.
Ultrasound or MRI scans are not required to diagnose frozen shoulder.
Typical features in the medical history and clinical examination are:
It is often a condition that patients have managed themselves for a period of time using over-the-counter painkillers and seeing therapists. When significant improvement is not experienced the patient often consults their GP who may refer the patient to an orthopaedic surgeon specialising in shoulder surgery for an opinion and further treatment.
The treatment strategy for this condition depends on which of the stages of frozen shoulder the patient is in. In the early painful 'freezing' phase the emphasis is on pain control. Painkillers and anti-inflammatories are usually commenced in the first instance. An injection of steroid into the shoulder joint (intra-articular injection) can also be used and often gives temporary improvement in pain control. This injection can be repeated after a further 6 weeks if the benefit from the first injection was significant. Some GPs are happy to perform this injection but it is more often performed by a shoulder specialist. The steroid injection may be combined with a fluid injection to dilate and stretch the capsule (hydroxylation). There is no significant evidence that injections of steroid into the joint do harm although oral tablets of steroid are not recommended due to the general side effects in the whole body that these can cause. During this painful 'freezing' phase physiotherapy exercises are not recommended as the pain limits the ability to perform the rehabilitation exercises. Also attempting these exercises when the shoulder is so painful can be counterproductive.
When the shoulder enters the 'freezing' stiff phase, and the pain has subsided, then physiotherapy with stretching exercises can be commenced and may be of benefit although improvement is usually slow.
If these methods fail to improve the symptoms or the patient wishes to expedite their recovery rather than wait on average 2 1/2 years for the condition to resolve then surgery is an option.
Surgery for frozen shoulder
The aim surgery is to expedite the patient’s recovery from frozen shoulder by more rapidly alleviating their pain and improving their shoulder range of movement.
There are 2 options for surgery to treat frozen shoulder.
Each procedure has its benefits and risks. Recent studies have shown that patients experience greater and quicker pain relief and return of full movement with an arthroscopic capsular release and this is usually the procedure of choice in my practice.
1. Manipulation under anaesthetic (MUA)