Frozen Shoulder Adhesive Capsulitis
By Joe de Beer
Frozen Shoulder, also known as adhesive capsulitis, is a condition characterised by stiffness and pain in the shoulder joint.
Signs and symptoms typically begin gradually, worsen over time and then resolve, usually within one to three years.
Frozen Shoulder is a condition with no known cause in the majority of cases, with spontaneous onset. It is most common in females (40-50 years), but could affect males and other age groups. It may follow injuries, operations or be associated with medical conditions like diabetes mellitus, hypothyroidism, heart conditions, stoke and others. It is referred to as “adhesive capsulitis” suggesting that the capsule is inflamed and adhering (clinging) to the joint, causing pain and limitation of motion.
Fig. 1. An inside view of a frozen shoulder: note the extremely red and inflamed inner lining (synovium) of the shoulder. Any motion, especially if it is a quick and excessive movement pulls on this tissue and causes an intense experience of pain.
Severe pain and restriction of movement. Night pain can be especially troublesome and with sudden movements intense pain may follow, e.g. reaching out to grab something. Reaching the hand up behind the back is usually a problem due to the restriction. To reach overhead the shoulder blade has to be lifted (see picture below).
Pain may be felt in the shoulder, spreading up the neck and even down the arm into the hand.
In some cases the shoulder blade may protrude at the back, referred to as “pseudo-winging” of the scapula (Fig. 4).
Fig.2. The range of motion is always decreased especially the external rotation with the arm by the side – here the limitation of external rotation of the left arm can clearly be seen.
Fig.3. The stiffness also makes it impossible in some cases to elevate the arm fully. In this case the inability toraise the arm is apparent. The restriction may often be less than shown here.
Fig.4. Due to the shoulder stiffness the shoulder blade may be pushed into an abnormal position of “winging”.
Due to this abnormal position of the shoulder blade (Fig 4.) there is traction on the large nerves in the neck (brachial plexus) and this causes pain in the neck, shoulder and down the arm and at times into the hand.There may even be nerve-like symptoms down the arm and into the hand e.g. numbness and tingling. The position of the shouder blade may also result in a dragging feeling in the back muscles attaching to the shoulder blade (the “peri-scapular muscles” or rhomboids as they are called).
Accessory Signs of Frozen Shoulder
1. 2. 3.
1. Winging of left scapula and tenderness over scapula border
2. Tender brachial plexus
3. Tender over the coraco-humeral ligament just lateral to the coracoid
Most clear up in anything from six months to as long as three years, even without any treatment and the fact that the condition mostly clears up in time should relieve the anxiety of patients “that it will last forever”. In a small number of patients the stiff phase can remain in the long term, and may need addressing with a capsulotomy procedure.
The Four Stages
- Stage 1: ”Inflammation”” (0-3 months). The lining of the joint (synovium) is inflamed. Moderately severe pain.
- Stage 2: “Freezing Stage” (3-9 months ) Synovitis and scar formation in the underlying capsule. Severe pain.
- Stage 3: “Frozen Stage” (9-15 months). Minimal pain, marked stiffness due to scar formation in capsule.
- Stage 4: “Thawing Stage” (15-24 months). Little pain, movement increases.
Medication: A person suffering from frozen shoulder may suffer severe pain and should be aided with pain killers, anti-inflammatories and sleeping tablets if necessary. As this is a self-limiting condition with an “end point” the medication will only be necessary for a limited period.
In most cases we manage the condition with Cortisone Injection into the joint. The injections are performed accurately using ultrasound control to ensure placement into the joint. A second injection is used to do a suprascapular nerve block simultaneously. We repeat the injection on monthly intervals for a maximum of three months. The effect of this is to fast forward the process of frozen shoulder towards resolution. This is usually beneficial in 80% of cases. It may be helpful in stage 1 and 2 (see above). Given early, such an injection may be of great benefit.
The injection has to be placed accurately into the joint as an injection into any adjacent area around the shoulder will not be effective.
More recently it has been shown that “multisite injections” are potentially of great benefit for frozen shoulder. The cortisone injection is injected into various anatomical sites around the shoulder: the glenohumeral joint just outside the capsule; the subacromial space; the coracohumeral ligament; and the posterior superior capsule. To be able to administer such injections the doctor injecting has to be ultrasound literate, in order to place these injections accurately.
In diabetic patients with “diabetic frozen shoulder” there may be a problem with using a cortisone injection due to the fact that cortisone may elevate the blood glucose.It is imperative to check the blood sugar in such a patient to avoid injecting cortisone into a patient with an uncontrolled level of blood glucose.
“Brisement” (Hydrodilatation) In this procedure a large volume of sterile fluid (Saline solution) is injected into the joint to stretch and “pop” the capsule. The fluid is injected with ultrasound control to ensure accurate intra-articular placement. In some patients this has shown to have good results.
Physiotherapy consisting of gentle stretching exercises may be done although aggressive stretching should be avoided. The latter is not only very painful but has been shown to prolong the course of the condition.
In some cases the stiffness remains a problem, and an arthroscopic (“key hole”) procedure may be of great benefit. The stiff capsule and ligaments are released to regain motion, and relieve pain. After the procedure the patient is encouraged to move the arm straight away, and no sling is worn. Discharge from the hospital is on the same or next day. The patient may resume normal activities within a day or two.
An arthroscopic instrument is used to release the tight capsule
Patients are encouraged to move the arm immediately after the procedure
Frequently asked questions
May I use my arm while suffering with a frozen shoulder?
A. Yes, definitely- movement is rather good than bad, although painful. During motion of the shoulder one pulls on the tight, inflamed capsule resulting in pain, but not damage.
Is Frozen Shoulder caused by an injury?
A. Only in certain cases, but most are ”out of the blue”, due to no apparent cause.
If a patient develops a frozen shoulder after a shoulder operation does it imply that “something has gone wrong”?
A. No, not necessarily: certain patients are more prone to developing a frozen shoulder than others, e.g. females in the middle age group as well as diabetics.
After recovery, could the Frozen Shoulder come back again?
A. It usually never recurs in the same shoulder and rarely in the other shoulder.
Does Frozen Shoulder always require treatment or even operation?
A. Frozen Shoulder will recovery spontaneously although an injection (especially in stage I or stage2 ) may speed up recovery.
How long will I take to get better?
A. The total duration of the process is anything from 6 months to 3 years. It is difficult, in a specific person, to predict the duration.
The message is that frozen shoulder is a self-limiting condition not requiring any operation in the majority of cases. In fact an erroneous operation due to a wrong diagnosis may aggravate the pain of frozen shoulder immensely.