Frozen shoulder

Frozen shoulder or adhesive capsuitis is characterised by shoulder pain and stiffness.
It most commonly happens for no reason, on occasion it may follow trauma or shoulder surgery.
It is more common in diabetic patients in whom it tends to be more severe.

General
A true frozen shoulder has three phases an inflammatory phase which is characterized by a deep seated burning shoulder pain often worse at night and affecting the patients sleep.
This is followed by the frozen phase this is characterized by increasing stiffness, the pain improves but does not go away completely particularly if the arm is suddenly moved, to swat a fly or grab a cup for example. This causes a sudden sharp pain.
The last phase is the thawing phase, here the range of motion improves and pain improves.
Patients will go through all three phases in general over 2 years, some quicker some slower at the end, ending up with a good shoulder.
Diabetic patients may take longer, over 5 years.

Diagnosis
The diagnosis is made on the history depending on the phase of the disease. Normally severe pain radiating down over the side of the shoulder.
The most characteristic physical finding is stiffness, particularly loss of external rotation.
The diagnosis is in part a diagnosis of exclusion, ruling out other causes for a stiff and painful shoulder

X rays are needed to exclude arthritis of the glenohumeral joint (ball and socket joint) and exclude calcific tendonitis.
In atypical cases an MRI or ultrasound scan may be needed, but is not needed in all cases.

In the early parts of the inflammatory phase the diagnosis may not be clear and often a diagnosis of impingement or tendonitis is made.

Treatment
There is no single miracle cure for frozen shoulder, several treatments have been tried.
If nothing is done most patients will go through all three phases over a 2 year period and end up with a good shoulder.
Two years however is a long time to wait.

In the early inflammatory phase treatment is directed at pain relief and controlling the inflammation.
The best pain killer being a non steroidal anti inflammatory (NSAID) if you can tolerate them.
It is important to control the pain, to limit the pain spasm cycle.
See pain killers.

Another way to control the inflammation is a steroid (cortisone) injection. Steroids are good for reducing infammation but not good for tendon healing.
The response to a steroid injection is variable.
It is worth trying one injection, at a push a second, but repeated steroid injections are bad for the rotator cuff.

Physiotherapy in the early inflammatory phase can sometimes seem to make it worse. It is not about 5 or 10 minutes with a physiotherapist but continued gentle stretching and exercises to maintain as much movement as possible.

Treatment in the frozen phase is all about returning smooth movement to the shoulder. A physiotherapist can show you stretches and execises but it is about continually stretching and strengthening of the shoulder in your own time.
See stiff shoulder.

Hydrodilatation - Hydrodilatation is a procedure undertaken with you awake under local anaesthetic. A needle is inserted into the shoulder and fluid is introduced into the shoulder to distend and loosen up the contracted capsule.
It is important to do your physiotherapy after the procedure to maintain the movement gained.

Surgery
Surgery is not normally considered till 6 - 9 months from the onset of symptoms. If performed too soon in the inflammatory phase the shoulder will just stiffen up again. There is no absolute need for surgery, only if the stiffness and pain persists and the shoulder does not unlock with continued gentle persuasion.
In the past this involved a manipulation under anaesthetic, the risks being fracture of the arm, damage to the nerves and tearing of the rotator cuff.

If surgery is considered nowadays this usually involves arthroscopic shoulder surgery, release of the contracted tissue, followed by a gentle manipulation. See arthroscopic capsular release.