Frozen shoulder (adhesive capsulitis)

WHAT IS IT?

Adhesive capsulitis and frozen shoulder are synonymous terms used to describe a stiff and painful shoulder that isn't due to arthritis. The capsule (watertight lining of the joint) of the shoulder joint becomes inflamed, thickened and scarred, causing pain and stiffness. It occurs in about 2% of the population, most commonly in those aged 40 to 60 years old, and more often in women than men. It is also much more common in diabetics, and the reason for this is not fully understood.

WHICH PART OF THE SHOULDER IS AFFECTED?

The joint capsule is a sac that encloses the joint and holds the fluid that bathes and lubricates it. The walls of the joint capsule are made up of ligaments that attach bones to bones. The joint capsule is normally very supple and allows a large amount of slack so the shoulder is unrestricted as it moves through its large range of movement. Capsulitis (inflammation of the capsule) considerably limits the shoulder's ability to move and causes the shoulder to become very stiff (freeze).

WHAT CAUSES IT?

The exact cause of frozen shoulder is not fully understood. Often an injury or accident may precipitate it or it may develop after surgery, but often no particular reason for it can be found. It occurs much more commonly in diabetics and those with thyroid problems but it is not known why. One theory is that it is an overreaction to injury whereby the tissue ‘over-repairs’ itself.

WHAT ARE THE SYMPTOMS?

The symptoms change as the problem develops, usually through three phases:

Freezing: with possibly no apparent precipitating event, the shoulder becomes progressively more painful. The pain is usually aching in nature and felt vaguely over the shoulder, over the back and down the arm. Trying to move the shoulder aggravates the pain. The pain can be very severe and cause difficulty sleeping. The shoulder also becomes gradually more stiff, losing its range of motion. This phase typically lasts between 6 weeks and several months.

Frozen: during this phase the joint become more and more stiff but the patient may experience some improvement in their pain. This phase typically lasts for approximately 6 months.

Thawing: the stiffness slowly improves. Complete recovery back to normal, or near normal, strength and range of motion takes, on average, 2 years.

WHAT IS THE TREATMENT?

This is a self-limiting condition which means it should get better on its own. The trouble is, it often takes longer than most patients find acceptable. The aim of any treatment is to fast-forward the patient along the disease pathway to relieve the pain and restore the range of motion sooner than it would come anyway.

NON-SURGICAL TREATMENT:

Treatment of adhesive capsulitis can be frustratingly slow. The vast majority of cases eventually improve, but the process can take many months. The goal of your initial treatment is to decrease inflammation and maintain existing movement of the shoulder. Your GP will probably recommend anti-inflammatory medications, such as ibuprofen. You should remember that overwhelmingly, the vast majority of frozen shoulders eventually return to a normal, or very near normal, shoulder.

During the early stage, your doctor may recommend an injection of cortisone and a long-acting anaesthetic to reduce inflammation. Cortisone is a steroid that is very effective at reducing inflammation. Controlling the inflammation relieves some pain and allows the stretching program to be more effective.

Physiotherapy can be helpful in maintaining the range of motion and is often a critical part of helping you regain the motion and function of your shoulder. You will often be given exercises and stretches to do as part of a home program. However, during the painful phase it may not be at all comfortable or effective.

You may be offered a procedure called Fluoroscopic-guided hydrodilatation. This is an x-ray guided injection as done done whilst you are awake (no general anaesthetic required) and is usually done by a radiologist (a doctor specialising in x-rays and scans). It is x-ray guided to make sure the needle is definately in the main shoulder joint. When that is confirmed, a large amount (approximately 200 mls) of saline (sterile water) is injected into the shoulder under a degree of pressure. You may feel a full sensation in the shoulder or like it is stretching and swelling up. The aim is to stretch it up until the capsule bursts. Only the capsule bursts ! - and at that point you may feel relief of the stretching sensation. None of the important anatomical structures are damaged. The radiologist may then inject steroid into the shoulder to calm the inflammation down. The process takes about 30 minutes. Patient's reports are variable. Most find it an odd sensation and perhaps uncomfortable because injections tend to be. A small number find it painful, in which case the procedure can be stopped at your request. You then need regular physiotherapy afterwards (within 48, max 72 hours, of the procedure). This is to keep the capsule stretched, otherwise it will stick back down again and you're back to square-one. I find that the pain relief is usually very good from this procedure but not so much the improvement in range of movement. Furthe recovery will take place naturally but it can certainly move a patient with frozen shoulder from not coping at all, to coping.

SURGICAL TREATMENT:

Arthroscopic Capsular Release. This is a key-hole operation done under full general anaesthetic when it becomes clear that non-surgical treatment has failed. The surgeon uses an arthroscope (camera – see section on shoulder arthroscopy) to see inside the shoulder. During this procedure, the surgeon can accurately cut and remove the thickened scar tissue to improve movement and break the cycle of painful inflammation. An MUA (Manipulation Under Anaesthesia) is also performed to tear the capsule. Often a steroid injection is also given to help reduce the inflammation. You are then woken up from anaesthetic and will wear a sling just until you can start to move your shoulder after the nerve block. You will need to see a physiotherapist soon afterwards to keep your shoulder moving.
I find the results of capsular release are usually the most dramatic, in terms of pain relief and range of movement, than any other treatment for frozen shoulder. The slight drawback, of course, is that you need to have a general anaesthetic in order to have it done.

Spire Elland Hospital

Elland Lane
Elland
HX5 9EB

For an appointment, telephone:
Outpatient Bookings on 01422 324 069
Self pay enquiries on 01422 229 597
Main Hospital on 01422 229 632

BMI The Huddersfield Hospital

Birkby Hall Road
Huddersfield
West Yorkshire
HD2 2BL

Reception: 01484 533 131

Department of Orthopaedics & Trauma

Calderdale and Huddersfield NHS Foundation Trust
Huddersfield Royal Infirmary
Acre Street
Lindley
Huddersfield
HD3 3EA

NHS Secretary:
Mrs Margaret Thomas
Tel 01484 342 343

NHS Clinics

Trauma:
Calderdale Royal Hospital (Halifax) and
Huddersfield Royal Infirmary

Elective Shoulder and Elbow problems:
Friday morning at Calderdale Royal Hospital, Halifax

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