What is Frozen Shoulder?
Frozen shoulder (also known as adhesive capsulitis) is a condition of the shoulder where symptoms of pain and stiffness gradually worsen over months and sometimes years. At times, varying other types of shoulder pains are labelled as ‘frozen shoulder’ however true frozen shoulder is actually the significant reduction of movement in the capsular pattern. This means that you are unable to move the shoulder far from your side, reach behind your back or indeed rotate it outwards due to pain and stiffness. It has 3 stages which vary in length and can overlap:
During stage one, often referred to as the “freezing” phase, your shoulder will start to ache and become very painful when reaching out for things.
The pain is often worse at night and when you lie on the affected side. This stage often lasts for two to nine months.
Stage two is often known as the “frozen” phase. Your shoulder may become increasingly stiff, but the pain does not usually get worse and may even decrease.
Your shoulder muscles may start to waste away slightly because they are not being used. This stage usually lasts 4 to 12 months.
Stage three is the “thawing” phase. During this period, you will gradually regain some movement in your shoulder. The pain will begin to fade, although it may come back occasionally as the stiffness eases.
You may not regain full movement of your shoulder, but you will be able to carry out many more tasks. Stage three can last from five months to many years.
What causes Frozen Shoulder?
Frozen shoulder occurs when capsule surrounding the shoulder joint becomes inflamed and thickened. The pathophysiology behind why this happens is unknown however the following can increase your chances of developing it:
– A previous shoulder injury or shoulder surgery
– Dupuytren’s contracture (a condition where small lumps of thickened tissue form in the hands and fingers)
– Other health conditions, such as heart disease and stroke
Studies of the epidemiology have also highlighted that Frozen Shoulder is more common in women than men and it is most likely to occur between the ages of 40 and 60.
How can it be managed?
We know that frozen shoulders will eventually improve by themselves but this can take up to several years to do so. As you can imagine, this level of pain, stiffness and lack of function is not acceptable to most people for this long, so alternative treatments are sought.
Frozen shoulders can be extremely painful, especially in the early stages of the condition. Your GP may prescribe you painkillers, such as paracetamol, a combination of paracetamol and codeine or a non-steroidal anti-inflammatory drug (NSAID).
Some painkillers, such as paracetamol and ibuprofen, are also available from pharmacies without a prescription. Always follow the manufacturer’s instructions and make sure you are taking the correct dose.
If painkillers are not helping control the pain, it may be possible to have a corticosteroid injection in your shoulder joint.
Corticosteroids are medicines that help reduce pain and inflammation. They may also be given with a local anaesthetic.
These injections can help relieve pain and improve the movement in your shoulder. However, injections will not cure your condition and your symptoms may gradually return.
Corticosteroid injections will not be used after the pain has gone from your shoulder and only the stiffness remains.
Having too many corticosteroid injections may damage your shoulder, and the injections often become less effective over time, so your doctor may recommend having no more than three injections. You will need at least three to four weeks between these.
Evidence for physiotherapy to manage true frozen shoulder have been conflicting over the years. In my experience, in the early stages of the condition, physiotherapy can be extremely useful for pain reduction however, movement often remains restricted. There is however research supporting physiotherapy in the middle to late stages of the condition as well as after more invasive input. After such a long period of immobility the shoulder needs lots of encouragement and muscle patterning retraining to rehabilitate back to full function.
Manipulation under Anaesthetic (MUA)
MUA has been the traditional orthopaedic surgical management of frozen shoulders. Although slightly confusing, there is no surgical incision. This actually involves your specialist manipulating the shoulder joint into full planes of movement (whilst you are under anaesthetic).
The ideal time for manipulation of the frozen shoulder is at the stage when night pain is decreasing but the stiffness has reached a maximum. Physiotherapy at this stage usually makes the shoulder more painful but is of course invaluable immediately after the manipulation and possible steroid injection.
This is a relatively new procedure that is becoming more and more popular for the management of frozen shoulders. This involves a small amount of fluid being injected into the shoulder joint which then expands the capsule. This ‘distension’ of the shoulder joint with fluid is thought to disrupt adhesions (scar tissue), thereby opening or freeing up the joint allowing improved range of movement. The evidence is building around this less invasive procedure having benefits to pain, range of movement and function in patients with frozen shoulder. Smaller studies are also showing that distension with steroid injection appears to be more effective than a steroid injection alone. When compared with a MUA, evidence suggests that it is as effective, with less complications.
Many shoulder complaints are placed under the umbrella term of ‘frozen shoulder’ so it is always best to have a full assessment with a musculoskeletal specialist, such as a physiotherapist.
Physiotherapy can be useful for pain relief in the early stages and is extremely important once the stiffness naturally starts to lift or you undergo a MUA or hydrodilation.
If you are unsure of your shoulder diagnosis or whether it is the right time for you to start physiotherapy, do Contact Us as early intervention will significantly improve timeframes for recovery.